Monday, May 24, 2010

new hurdles

I've made peace with our preschool situation. I'm grateful we have what we do, even if it's not everything I'd like. I'm trying so hard to step up and supplement more at home, which is what I BELIEVE in. It's just easier said than done. We're just a couple weeks from the end of the year and then I'm hoping like crazy that I can use the summer to find a good routine for practicing speech, counting and ABC's at home.

Meanwhile, this weekend we got a letter from our insurance company telling us that they denied our request for more therapy visits. Here's how it works - we get 30 visits per calendar year per individual. These visits include speech therapy, occupational therapy, physical therapy, any kind of behavioral therapy, etc... Just 30 a year - not even once a week. We requested more, which is the first step (and hopefully the only one necessary). They said we couldn't have more visits. Now we face an appeals process that could take 6 months if we have to go through all 3 levels. They continue to pay once you start the appeal process but they will ask for the money back if they never approve.

Carver goes to speech 2x/week and we've elected not to do any other therapy for the sake of time, sanity and money. Really, his speech is his most noticeable delay. Besides not being potty trained or knowing how to ride a bike, etc... but those things don't show quite as often. :)

If insurance doesn't cover therapy, we're looking at around $200 a week in therapy costs. Or we could scale back to $85-100/week if we go down to one day. Obviously, this is a significant cost. And a huge dilemma. How can we NOT get the help we need for Carver? But how can we justify so much money out of pocket? Where will it come from? Is it worth draining our savings account for a few years of speech therapy? These are hard questions.

First step - write to the insurance company. They wrote:

"This benefit restriction is not a determination of medical necessity. This denial is for payment purposes only. if you choose to receive the service, you will need to assume the cost."

Does this mean they don't care that therapy is medically necessary? Is that really irrelevant? How can health insurance deny medically necessary treatment? How are we supposed to get the care we need in a medical system built around the concept of insurance if the insurance won't participate? It's incredibly frustrating.

And so I'm incredibly frustrated. Disappointed. Overwhelmed. Discouraged.

4 comments:

Steve and Hailey said...

I have no great advice, but I feel frustrated with you. I know in my previous insurance I learned SO much and I fought everything I could and I ended up winning one appeal (but it was fairly simple and spanned two letters and about a month). It seems so difficult to pay back the money if you don't win?!?

I guess I always hope that there is someone in the neighborhood or ward that has the necessary skills and will help for less $. Another thought is that I tutored a couple children and their families would raise money for therapy...okay I'm not exactly sure how, but I vaguely remember one family having a blog and maybe the mom did photography and the money went to therapy...Of course that requires too much time.

I often feel the lack of money and resources. Usually I can figure out a way around my need/want. I guess for the time being you are the most amazing resource to Carver and Derek will be incredibly skilled in fighting the insurance company and then there's prayer...

Steve and Hailey said...

whoa who left the obnoxiously long comment?

Danielle said...

I have a speech therapist in our ward if you ever want or need to talk with her. She might be able to give you ideas.

Natalie said...

Hi my name is Natalie Lambert. I just wanted to say keep up all your hard work. Kim Higueria used to be in my ward and she pointed me to your blog. I have two boys with PDD-NOS and have SPD along with their diagnosis. I know how hard it is to get therapy covered. We live in Massachusetts and fortunately for us they have classrooms designed for my children but it sure was an uphill battle to get to this point. If you ever need someone to vent to about any of this feel free to contact me. my blog is www.lambertfamily4.blogspot.com. I hope this isn't too weird, it was just nice to read about someone going through the same thing.