Resources for fighting insurance
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KathyK posted this link a week or so ago (thanks!), but I thought it deserved its own topic, where everyone could see it. This site is particularly helpful for California residents, but can be an inspiration for residents of other states, too, particularly those with mandate for covering autism treatments. It includes sample letters. The site also includes a section of helpful links, including links to a yahoo group about autism and insurance, and links for people living in a few other states. http://www.insurancehelpforautism.com/index.html If anyone else has any helpful insurance-related links, feel free to post them under this topic. Today www.specialchildren.about.com tipped me about "Get Human." Here's what specialchildren has to say about it: <quote> It's frustrating enough calling my insurance company to debate payment on some bill for my kids. What gets my blood boiling before I even have that discussion is the need to navigate an electronic menu with a chilly virtual voice that doesn't like my answers. By the time I get to a live representative, I'm already ticked. If you'd like to cut to a human right at the beginning of these calls instead of after minutes of punching in digits or arguing with robots, the Get Human database can help. It gives instructions for reaching a real person at a variety of companies, including insurance agencies. There are also general rules for getting through, in case your company's not on the list. The instructions for my insurance company to say "Get associate!" worked last time I called, and I had a lovely, low-blood-pressure chat because of it. Got my claim reconsidered, too. <end quote> Here's the list of insurance companies (they also have lots of other types of companies): http://www.gethuman.com/#insurance Here are general tips for getting connected to a human: http://www.gethuman.com/tips.html Here's a link to the Department of Insurance website for each state: http://www.naic.org/state_web_map.htm Kristys had some tips under these topics: http://www.autism-pdd.net/forum/forum_posts.asp?TID=23928&am p;am p;am p;am p;PN=1 http://www.autism-pdd.net/forum/forum_posts.asp?TID=25094&am p;am p;PN=1 Another of our members has shared her experiences here: http://blog.myspace.com/index.cfm?fuseaction=blog.view&f riendID=112392203&blogID=361629165 Complex Child Magazine has an article called "Writing Winning Insurance Appeal Letters" with tips and a sample letter: http://www.articles.complexchild.com/00012.html Wright's Law has a set of articles on "Parental Protections" to prevent disability-based discrimination in insurance benefits, etc. (thanks for the tip, amie). http://www.wrightslaw.com/info/protections.index.htm Here are coding tips and a sample letter for getting TheraTogs covered. You might be able to use/adapt these to get other Sensory Integration equipment covered. http://www.theratogs.com/Doc/pdfs/reimb/SPD_Reimbursement_Gu idelines_May07.pdf
http://www.spdbayarea.org/insurance_questions_for_OT.htm - insurance questions to ask for OT http://www.spdbayarea.org/SPD_diagnosis.htm - Sensory integration/OT have to be billed using with a diagnosis other than Sensory Processing Disorder (or autism). FYI: SPD doesn't exist yet in the International Classification of Diseases (ICD), but now exists in the Diagnostic Manual of the Interdisciplinary Council on Developmental and Learning Disorders (ICDL). The council is chaired by Dr. Stanley Greenspan. It's a step in the right direction. This short article includes a link to the new codes. Found this today: "How to get your child's autism treatments covered by health insurance." http://autism.about.com/od/financialresources/ht/insuranceti ps.htm?nl=1 Patient Advocate FoundationThe Patient Advocate Foundation is a national non-profit organization that serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job retention and/or debt crisis matters relative to their diagnosis through case managers, doctors and attorneys. Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability. http://www.patientadvocate.org I have read the above links and they have been very helpful. I am just starting my battle with CIGNA. Does anyone know if there is a procedure code for ABA? I think these are some of the ones that are typically used. I don't know of any specifically for ABA. 96102 (evaluations by non-PhD staff) 90847 (family therapy with the patient) 90806 (behavior modification) 99199 (unlisted special service) For director and supervisor time 90808 (case supervison) Good luck with your fight! What state are you in? I am in Houston, TX. DS is 2 years and 4 months old and we are getting ST from ECI but its not very good... The ABA is private and in-home. The provider is a company run by parents so I am trying to do the majority of the paperwork by myself.
Wall Street Journal article: "Pushing back when insurers deny coverage for treatment" (not autism specific): http://online.wsj.com/article/SB122230334120773621.html
Here are some things I had forgotten to add to this topic: http://www.tacanow.com/health-insurance/sample_insurance_let ter.htm - sample insurance letter http://www.tacanow.com/pdf/Dr_Lovaas_Criteria_July2005.pdf - help arguing that ABA is essential http://www.tacanow.com/health-insurance/health_ins_reimburse ment_tips.htm - article with lots of insurance related links. http://www.talkaboutcuringautism.org/medical/biomedical-on-a -budget.htm - Biomedical on a budget, which mentions how to get insurance to cover some testing.Interested in legislating insurance coverage for autism? If you go to State Initiatives, you can find out the insurance legislation status in your state, and you can get involved with the effort (tip from mbmom). Easter Seals also has information on legislation. Easter Seals and the Autism Society of America have partnered together to prepare a state-of-the-state report of autism services in the 50 states, the District of Columbia and Puerto Rico. The profiles highlight the number of children with autism who have received the state’s special education services, state insurance coverage for autism if available, Medicaid services specific for individuals with autism, educational programs provided to students with autism or training that focused on autism, special education criteria, other state-led resources, and sponsors of autism legislation. http://www.easterseals.com/site/PageServer?pagename=ntlc8_au tism_state_profiles Tip from twinsohmy: http://health.groups.yahoo.com/group/autism_insurance_inform ation/
In the current issue of Time, there's an article called "The Health Care Crisis Hits Home" by Karen Tumulty. The author describes her brother's insurance trouble and how they dealt with it. He is an adult with Asperger syndrome, employed but insured only with serial short-term policies. Even though he had continous coverage with the same company, each 6 month period was considered a separate policy. A test in one period caused them to refuse coverage for treatment in the next because it was a "pre-existing condition". The author and her brother live in Texas, which has more than its share of un- and underinsured. They got help from CareLink in Bexar County hospital district (covers people who earn 200% of the poverty line). They also got help by filing a complaint with the state Department of Insurance. It took them 10 minutes to file the complaint on the internet, and they got their answer in less than a month! With the state insurance department sniffing around the insurance company actually agreed to pay 2008 bills! I have a link to contact information for the department of insurance in all 50 states on page one of this topic. Here's a link to the Time article: http://www.time.com/time/nation/article/0,8599,1883149,00.ht ml For me, the article can be summed up in this quote: "just about anyone could be one bad diagnosis away from financial ruin." The employed and the unemployed, the insured and the uninsured are really all in the same boat.
Under another topic, the following insurance link was posted. It includes a step-by-step list for getting insurance coverage for ABA, including a sample treatment plan letter. |
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