I don’t think insurance companies should be demonized the way the Democrats have been doing; but they indeed have their problems and can be very annoying and short-sighted.
Agent Murphy had his regular speech therapy on Monday. After we got home, the CHOA location we go to contacted us to tell us they had just been informed by Aetna that all the visits since the beginning of February are being denied. Mind you, the therapy site contacted Aetna sometime in December to re-verify benefits for 2010 and were told everything is fine and we’re covered for 60 visits per calendar year. He’s had maybe 13 so far in 2010. And all the appointments in January processed normally. By the time I spoke with the insurance specialist, Candy, at the therapy office, she told me our therapist was already going to war pulling together information on medical necessity. She was drafting a letting about it which she was going to get over to our pediatrician’s office so they can sign off on it too.
Candy asked me to call Aetna to find out what I could from my end while they start the appeal process. I spoke with Lisa C. at Aetna, who informed me that after some number of visits billed under the same treatment code, they want additional information to find out if the treatment will bring the patient to a “restorative state” before they continue to pay. She said I was in a good position if the provider was going to go to bat on the Agent’s behalf, because they’ll have all the medical documentation Aetna is looking for. Her sense was that when they have the documentation they’ll go back and pick up all the denied claims and reevaluate them.
Well, okay, wanting to know if a course of treatment is effective rather than futile makes sense. But is denying coverage to force an appeal the only way we can accomplish that? How about a simple request to provide certain medical documentation by a certain date, after which treatment won’t be covered until the documentation is provided? No, no. We can’t do anything so reasonable. Just deny the claims. And interrupt the treatment. (Unfortunately, Candy was out sick today so I couldn’t talk to her about whether we should keep proceeding with his visits normally or suspend them until this is resolved; so the person I did speak with suggested that it was best to be safe and cancel tomorrow’s appointment and then get better guidance from Candy when she’s back. Fact is, if they’re going to end up denying coverage in spite of the documentation, we can’t afford to be on the hook for more than we already are; even on the covered visits, we’ve still paid a pretty penny.) Of course, we’ve just started gaining some momentum since introducing the communications book and device. And I hope this interruption doesn’t mess that up. Fabulous, right? We’re not sure if this treatment is effective enough, so we’re going to interrupt it and make it less effective. Stupid, stupid, stupid.
Anyway, we did get our communications book from Miss Lindsay on Monday and we need to start using that at home. (We need to make braille labels on it for Daddy, too.) The plan is to primarily use the book at home and the device (the loaner) in therapy. Yesterday Agent Murphy did really well using the device. And he’s even trying to say the word himself when he pushes the appropriate picture. Miss Lindsay’s theory is that with the device as back up, he’s less frustrated about not being able to make all the sounds so he’s more willing to try them.