why doesn’t insurance pay for autism? | Autism PDD


So I called our health insurance co and they said they do not cover speech therapy "Services rendered for the treatment of delays in speech development, unless resulting from: disease; injury; or congenital defect."

It says its covered if the person has lost existing speech function (ability to express thoughts, speak words and form sentences) as a result of a disease process. 

I didn't argue just was getting info from them. 

So I'm thinking autism is not consider a disease? 

This is just depressing.

Any input, advice, suggestions?

I would move somewhere else if we could get some help.  What has everyone else done to fund their child's treatments?  We have some savings that it took 15 yrs to save and that will be gone soon.  We are doing ST, OT, and treatment for anxiety through a psy.  We want to start ABA asap and boy is that $$$$$$. 

This whole insurance thing not wanting to pay just really pisses me off.  I can't believe they would pay if she had diabetes or a stroke, or cancer, but they are basically saying, fu if you anyone in your family has autism.  wow. 


Unfortunately, it is common practice for insurance companies to only cover speech therapy that is "restorative in nature."  And that is certainly what you will be told on the phone.   It is typically much easier to get OT and general psychiatric care covered.

That being said, don't lose hope.  I've managed to get 5 years of weekly private ST and OT covered, first with Cigna and then with Aetna (when my company switched providers in 2006).

There are a few things you need to do / consider:

-         Talk to all of your therapists as to what ICD-9 code they will use to code your invoices.  They often have significant latitude in what they are willing/able to submit.  If your child has both apraxia and autism, have them use the code for apraxia.  Never use codes 315.3, 315.31, 315.39 and 315.9.  They are codes for developmental speech and language disorders.  They typically aren't reimbursed without a huge fight. Good codes are 784.69 (apraxia), 315.4, 718.3 (hypotonia, sensory motor integration disorder and coordination disorder).  There's also a generic code of 783.4 for neurodevelopmental dysfunction.  When C started therapy at age 2 he had no diagnosis - he wan't a clear cut case and it could have been a variety of things, so the therapists coded his invoices as ICD9 Code 784.69 Apraxia and insurance paid up.  Once you find a code that works, stick with it!  A good therapist is usually willing to redo an invoice with new codes if the initial code doesn't work.  Sometimes codes need to be "rotated" :)  We have NEVER submitted using the ICD-9 code for autism!

-         Have your physician prepare a “letter of medical necessity” for you.  In this letter, the physician should clearly state that your child has a MEDICAL condition that requires TREATMENT.  DO NOT ever use the following words with your insurance company:  developmental, delay and therapy.  Don’t use them on the phone, don’t ever let the insurance company see them in writing.  "Developmental" and "delay" imply something the child can just “grow out of” on his/her own and “therapy” sounds like a nice to have.  The emphasis in all communications needs to be on your child’s medical condition and the recommended course of treatment.

-         Make sure all therapists know that you are submitting to insurance and that they will likely be asked to submit treatment notes and to be prepared to do so.  At least once per year my claims for C get denied because the insurance company “needs more information.”  I have my therapists bury them with paper and the claims get paid.

-         While we all get a generic booklet of things covered by our insurance, it is your legal right to view a copy of the "master policy."  Most people don't know this.  You can request it from your insurer.  This is the document that contains all of the small print that the insurance company uses to determine whether to accept your claim.  If you look at this BEFORE submitting anything, you will have a better idea of what codes to try.  If they don’t want to give it to you, or pretend to be clueless on the phone, ask to speak to a supervisor. 

-         If denied, perseverance is key.  Insurance companies expect 95% of people to give up and not go through the trouble of an appeals process.  If you fight smart you have a good chance of winning.  Also, if an invoice gets rejected, just resubmit it again.  Wait until the same invoice has been rejected twice before starting the appeals process.  You don't want to start the whole squeaky wheel process if you don't have to, and so many times when you resubmit a 2nd time you just get a different person who either doesn't know, doesn't care or just doesn't look that closely and it gets paid without a fuss.

-     Also, if you are insured through your employer's group plan, and you are having difficultly getting what you need, go talk to the head of your employee benefits department.  They can help push things through on your behalf.

I know it shouldn't have to be this hard.  Good luck.

Wow--Kristy. I wish I would have had that info a couple of years ago. We did have luck with apraxia and hypotonia codes on our old insurance, but not the new. It took us forever to figure all that out. We are still dealing with bills over a year old that keep getting denied. It's funny how it's covered one month and not the next. We had to fight them every month, but it always got covered under the old insurance. It was a full-time job trying to deal with the insurance companies.

Kristys -- would you mind posting that information under my collection of resources for fighting insurance?

http://www.autism-pdd.net/forum/forum_posts.asp?TID=18097&am p;KW=fighting+insurance

wow, thanks! Insurance is meant to pay for cures.  Autism is incurable.  Typically, health insurance stops paying for a therapy when it has been shown that the therapy is not longer helping the individual make progress.  We all pay insurance for different things and our premiums are based on the potential benefits we've agreed to pay for.  Most insurance contracts limit certain therapies, if those therapies are offered at all. There is NO intevention that is specifically for AUTISM.  However, there ARE interventions that address certain features of autism -- interventions that often ARE paid for, to a limited extent, by many policies.  For example, OT, PT and speech.  Of course, these interventions are limited, even when they are caused by an accident.  Developmental disability may be excepted in your insurance contract, but that means you haven't been paying the higher premium that would occur if developmental disabiity HAD been covered.  And no insurance company can be forced to cover dd unless your state has a law that requires it be covered. You can advocate with your legislators to try to pass a law that covers dd/autism.  In today's political climate, with autism being on the front page nearly every day, there is some hope that you might eventually be successful in changing the system.  But that's what it would take -- changing the system. And, of course, paying the higher premiums that better coverage would require.

TACA has on it's website "Health Insurance Reimbursement Tips & Tricks."  There is a lot of good advise.

http://www.tacanow.org/health-insurance/health_ins_reimburse ment_tips.htm

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