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Insurance, Been There…Done That…

Kathy Hennessy

One day, in a fairly irrational moment, I sat down and figured out what the total cost of speech therapy would be without insurance. I guess as the mother of two children with apraxia, I have developed a dark sense of humor about all of this. Where did I get my numbers? Honestly, I just guessed based on some things that I had read. I projected 3 times a week, $60 per hour for 5 years. Turns out the reality was; for the first child 5 days a week (off and on, give and take) for 7 years and about midway the price went up, and for the second child…well, lets just say hes still at it and its been almost 8 years.

If you do the math, you will see that my husband and I were in a position that we could not accept being denied by the insurance company. My husband is self-employed and our monthly premiums were more than our mortgage. I would like to share with you what worked for our family. Keep in mind, every insurance company is different, every policy is different, every state has different laws. Please remember that what worked for us may not work for you.
Our first evaluation for our oldest child was in 1992. Over the last 10 years I have developed my own little set of rules. Some of my rules came about from working as a paralegal and hanging around lawyers too much. Some of them I learned the hard way. All of them have come in handy at some time.

Rule #1 Never, ever, take no for an answer

Insurance companies seem to be in the habit of saying no right from the start. They will blame it on the lack of medical necessity, the fact that services are habilitative and not rehabilitative or that apraxia is a developmental disorder and insurance companies do not cover delays that are developmental. When an insurance company turns you down, you must follow all their rules for filing an appeal in order to protect your rights. Missing even one deadline can terminate your rights. When you file your appeal, send copies of all relevant documentation. Besides the speech therapists progress reports, letters from pediatricians etc, I always included letters from, the kids teachers, or anyone that dealt with my child on a regular basis, who would be able to note progress. Some insurance companies require proof of progress, so your speech therapist should be documenting every sessions progress. You need to periodically update your files to include all progress reports.

Keep a copy of everything you send. It will be easier to resend the packet when they say they never got it if you have everything together. I always sent my packets registered mail. It didnt stop the insurance company from saying that either the entire packet was lost or pieces were missing, but I could always prove I made the deadline.

I never assumed that the insurance company was organized enough to keep files from one denial to the next. Every time I had a problem, I sent my whole packet over again, from birth records forward. Anytime you send something to the insurance company, follow up with lots of phone calls. Make sure they have your information.

Rule #2 Keep perfect notes

When your child is diagnosed with Apraxia, stop at the office supply store on the way home from the doctor’s office. I’m just kidding, but getting yourself organized is essential to healing with you insurance company. I had a notebook that I used to keep just for when I talked to the insurance company. In my little notebook, I kept track of every call. I listed the date, the time, and who I was talking to, (Most of the time you can only get a first name. One friendly agent once told that they only give first names because they think people will call the agents at home and harass them. Uhm…), what the subject was and notes as the conversation proceeded. It got to the point that trying to deal with two children and their various insurance issues, I had to get two notebooks.

Keeping good notes is essential to getting and keeping coverage. One time, it was the day before Thanksgiving and I had the flu. I had been going round and round with this agent for days and she finally said that we were going to receive the coverage that we had asked for. I hung up the phone very please with myself. However, In my joy I had forgotten to get an approval number and when the insurance company refused to pay, I had no way of proving that we had been granted coverage.

The other thing youll need to get is a really big binder. There will be a lot of paper work as time goes by; evaluations, progress reports, letters sent and received, etc. Your claims will appear much more valid if you can recall facts and reports quickly.

Rule #3 Don’t be afraid to go up the chain of command

Try to remember that the folks who answer the phone at the insurance company are not the ones who denied your claim. They basically have a script to follow and have no other answers for you. However, no one has the right to speak to you in an unacceptable manner. I have had this happen when the clerk does not appreciate my persistence. Immediately ask for a supervisor and don’t be intimidated. Insurance companies are not therapists, nor are they doctors. They are not qualified to assess a child with a diagnosis of apraxia. Make sure that any paperwork sent by your therapist or doctor states that the treatment of apraxia is “medically necessary” and never, EVER use the term “developmental apraxia”. You will be denied immediately because to an insurance company “developmental” means its just a childhood issue that the child will eventually outgrow.

You are the link between speech therapy and the insurance company. Keeping a calm demeanor and good notes will go along way to furthering your cause.

Rule #4 Try to communicate with the same agent

This is next to impossible, but try to communicate with the same agent every time you call. Even if you have to leave a message and have that agent call you back, its worth it to establish a relationship with someone. Insurance agents are basically paid to say no to people like you and me. If you can become a person to them, it will be harder to deny your claim. In my case, every time the agent caught on to what I was trying to do, they wouldnt talk to me anymore, but it worked till they caught on.

Rule #5 Read and Understand your insurance contract

There are always loopholes in any contract. Find them and use them…your insurance company will if they can. Insurance contracts are even purposely ambiguous in places. This can benefit you as well as the insurance company.

Heres one little, legal scam that still amuses me. The insurance company says they will pay 80% of the allowable expense for speech therapy. You become very excited and proud of yourself for making your insurance company pay what you think they are obligated to pay. If your speech therapist charges $100 per hour, you figure youll pay $20 and the insurance company will pay $80. Great! Dont get too excited too fast…you have to find out what the allowable expense is, exactly. If your insurance company has an allowable expense of $50 per hour for speech therapy and your therapist charges $100, the insurance company will only pay 80% of $50. So you have to pay $20% of $50 and the remaining $50. What you really end up paying is $60 and the insurance company pays $40. Imagine my surprise when I did the math on that one. However, our therapist was a wonderful person and accepted the allowable expense, even though she was under so obligation to do so.

One of the most often used reasons for denial is lack of medical necessity. What you need to know is how your contract defines medically necessary. Not all contracts will define this term in the same manner. Once you have a definition, find out what they need to prove medical necessity. One of my children had repertory issues and antibiotics at birth. There were times when that was the deciding factor in coverage and not the diagnosis of apraxia. Make sure that your therapist always uses the term medically necessary when referring to your child.
Although you may see the term developmental apraxia in books you read on the subject, it is worth mentioning again, never use the term developmental when you are dealing with your insurance coverage. The term developmental means something entirely different to an insurance agent than it does to someone familiar with children diagnosed with childhood apraxia of speech. It is worth could be denied immediately because to an insurance company developmental means its just a childhood issue that the child will eventually outgrow. Researchers and clinicians sometimes use the term developmental to differentiate childhood apraxia of speech from adult onset apraxia usually associated with people who have had strokes or acquired apraxia usually the result of brain trauma.

Rule #6 Read and Understand State and Federal insurance laws

Understand the meaning of insurance fraud. When an insurance company makes statements to you in your policy or pursuant to the purchase of a policy, and then does not legally abide by such statements in the review and payment of claims made by you pursuant to the policy, you have a good argument that the insurance company has defrauded you of the insurance premiums that you have paid, or have been paid on your account, per your policy. Do not hesitate to throw around the term insurance fraud when talking to an insurance company, although only do so if you have specific facts to back up your statements and only upon a last resort. As always, it is helpful to have an attorneys attention to such matters if you can afford one.

Rule #7 Don’t be afraid to call your State Insurance Investigator

I started in the blue pages of the phone book and kept making calls till I found someone who could help me. The underlying issue here is perseverance…yours!

Keeping things straight when you have two children in therapy can be challenging, even for the insurance company. The insurance company at one point decided that it was no longer medically necessary for my daughter to receive speech therapy. I went round and round with them, until I couldnt do it any more. My husband began to prepare a lawsuit and filed a writ (the beginning of a lawsuit) notifying the insurance company what was coming. At the same time, they began to deny coverage for my son. When I called to find out why, the clerk wondered how I could expect the insurance company to pay for one child when we where suing them on behalf of another child. Im not a lawyer, but that didnt sound right even to me! It was a little after 5:00 PM when I called the State Insurance Investigator. He picked up the phone himself and 48 hours later all my problems were solved. The insurance company had ventured just this side of fraud. They may not respect me, but they seem to be a little afraid of the State Insurance Investigator. It s worth the call.

Rule #8 Perfect your paper trail

I cant say enough as to how important it is to create a good paper trail. Check out Peter Wrights website at and the article entitled Parent Advocacy: Documents, Records and Paper Trails .
The article refers mostly to dealing with school districts but most of this valuable information can be applied to insurance companies.

Keep track of every phone call that you make; who, date, time, what happened and every meeting that you might have. Get sympathetic letters from everyone involved with your child, the speech therapists, your doctor, independent evaluators, day care providers, pre-school teachers. Make sure professionals use the term childhood apraxia of speech and talk about the progress that is being made by your child. Insurance companies like to know that your child is making progress. I also got a copy of my childrens birth records and started the paperwork there. Remember to always send the insurance company copies and keep the original for your files. Some records can be hard to find after a while or even get lost in someone s file cabinet.

Rule #9 Have a good attorney

This is probably the last option any of us want to be faced with, but the reality is it may be the only recourse left at some point. If you have been reasonable and have reasonable expectations, if you have followed all the rules for appeal and are still being denied insurance coverage, hiring an attorney may be the last option available to you. Sometimes, a simple letter from an attorney may be enough to get the insurance company to comply with what is stated in the contract. Sometimes, you may have to take it a step further. Having a good paper trail will put a smile on your attorneys face and make the job easier.

An attorney might also be able to investigate whether an insurance company is complying with the Americans with Disability Act (ADA). A federal appeals court has found that ” if a federal statute like the ADA is violated, the Employee Retirement Income Security Act (ERISA) provisions allowing ERISA-covered health plans great latitude in excluding coverage for various treatments are preempted.” (Federal Eighth Circuit Court of Appeals, Henderson v Bodine Aluminum (CA8 Mo. 1995). Your attorney upon a review of your insurance policy may be able to determine that your insurance company has similar exposure under the ADA.
You can always call your local Bar Association and ask for a lawyer who is knowledgeable regarding special needs matters.

Rule #10 Always remember whom you are fighting this battle for!