Monday, March 23, 2009

Therapy and Insurance

Today Will had his last feeding therapy (Vital Stim) at the hospital. He is still not eating much by mouth. He still puts food in his mouth, chews, then spits it out. So why are we stopping the therapy that Will has shown so many improvements with, because of our insurance, that's why. Our insurance company will only pay for 20 therapy sessions during one calender year. They will pay for 20 sessions of speech therapy, 20 of physical therapy and 20 of occupational therapy but nothing more than that. It completely blows!

I have tried to appeal the denial but that is like fighting a battle with both hands tied behind your back, in the dark, while underwater, blindfolded...you get the picture. It is just ridiculous. Appealing the insurance company is a battle that I just will not win. It is much like the battle that I have been fighting with them since August to get them to pay for Will's pediasure. I can call and talk to one person that says it is covered, we order it from our supplier and then 2 months later we get a bill saying that our insurance company denied the charges. I call the insurance company and the same person who told me 2 months ago that it would be covered then tells me that the pediasure is a non-covered item on our plan. (insert head banging on the wall here) This cycle has been ongoing since August...it can wear on a person.

Will has been showing good improvement since we started the vital stim in January but is still not swallowing much. He swallows the "juices" that he gets from chewing the food in his mouth but doesn't swallow the food. He can stick his tongue out and wiggle it around. He can clear a spoon with his lips. He can drink baby food from a straw. And has been making many more sounds since starting the therapy in January. But today was our last day until 2010 because our insurance company blows.

I just really wish that insurance companies would let the doctors do the deciding on what treatment would be best for the patients and not base treatment on whether or not it is covered by the plan.

7 comments:

Brandi said...

Myssie,

Do you have a nurse case manager? I do and she seems to go to bat for me whenever there is a problem. In addition, our insurance allows extra therapies if it the reason is due to neurological problems. Since RTS kids have the medical diagnosis of mental retardation it is considered a neurological condition and more therapies can be granted.

What insurance do you have? I'm wondering if your policy has the same clauses that ours does. I would be glad to help if I can. Send me an email mrs.olives@yahoo.ccom and we can chat!

Kelly said...

Hey girl...I am with you! That sucks!

I hope you can figure something out.

Kelly W.

Cindy said...

I'm so happy to hear he's had improvement with the therapy, and so sad it has to stop too soon. Have you thought of finding a foundation to underwrite his therapy expenses? The only other solution I know is HMO...they don't have a limit on the number of treatments, if they cover the treatment to begin with.

If nothing else works, I hope you can be comforted knowing he likes to eat, and hopefully there are a few foods he can safely practice on without e-stim?

Kelly said...

That sucks, especially when he was making great progress. Kelly F

Corey Hudson said...

ok, thats just crazy!!! we would be out of therapy in 10 weeks if we were in that position.

does your state offer a waiver program for medicaid? we have medicaid as a secondary and they pay for everything thankfully!

we just recently found out about a backdoor to the waiver program in tx (its usually a 3-4 year waiting list)

good luck with your fight!!

Kristi said...

I'm sorry. I know how frustrating insurance companies can be. Good luck..

Michelle said...

Wow. Come move to NY. I've never had to pay a cent for anything for Austin. The state covers all therapy until 3 yrs old and then after that the school district does. It blows my mind to hear our RTS family talk about such struggles. It makes me very very thankful.