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What They Don't Tell You About Parenting A Special Needs Child: The Insurance Edition - Karen's Musings
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What They Don't Tell You About Parenting A Special Needs Child: The Insurance Edition

There's a lot "they" don't tell you about life.  Especially life with children.  And when you throw in triplets and an ADHD five year old?  Well, there's a whole lot that "they" edit out for fear of you running screaming from the room.  Today's topic?  Insurance companies. Today's blog subtitle?  Don't let the bastards get you down. 

Item the first?  I am *still* getting bills and EOBs for the triplets NICU hospitalization.  Note:  They were discharged from the NICU 1 year, 14 days ago.  I am still getting bills from the company that we rented Ellie's heart monitor for.  I'm getting these bills because the insurance company won't pay for them.  The insurance company won't pay for them because the bills are in Abby's name.  Abby never had a heart monitor.

But that's not what this post is about.  That's just an illustration of how stupid the insurance companies can be. 

Today's post is about ADHD and insurance companies.  You see, when you have a child with special needs, you're bound to run into all sorts of fun with insurance companies.  Insurance companies prefer you to have children who never get sick and who have no special needs.  They make money off of members who pay their premiums and never go to the doctor.  But when you have a child who starts going to a developmental pediatrician, a speech pathologist, a neuropsychologist, and heaven knows who else, well, the insurance company doesn't love you QUITE so much anymore.  

Here's the other fun part about ADHD:  ADHD is considered a mental health diagnosis, not a medical diagnosis.  Insurance companies don't really feel the need to cover mental health diagnoses without a lot of hoop jumping.  I guess they think you might abuse the system or something.  Because my favorite thing to do on a Tuesday morning is go see a therapist, or, say, a developmental pediatrician, just for kicks. 

Oh, and did I mention that most developmental pediatricians don't accept insurance?  At least not the ones in this area.  The ones that do are the ones that are affiliated with large hospital systems, but they have long waiting lists and aren't as good with personal followup.  My doctor is phenomenal about personally following up with everything and I get a call back within hours every time I call him for ANYTHING no matter how trivial.  He coordinates personally with every member of the J-man's team.  I wouldn't get that from any of the major medical centers - plus if I went to them, I'd STILL be waiting to get in for the initial intake appointment because their waiting lists are so long.  So no insurance.  We pay out of pocket, submit the claims to our insurance company ourselves and hope that they will reimburse us. 

For medical claims that are out of network, the insurance covers 60% of the allowable fee.  For mental health claims, the claims must be preapproved by the Employee Assistance Program (EAP), and are covered at 40%.  Mental health claims are also limited to 10 visits per year.  Each invoice includes a diagnosis code (J's is DSM IV's 314.01) and a CPT code (this is a procedure code).  The diagnosis code translates to ADHD, combined type.  The CPT code usually translates to "50 minute office consult", but has occasionally been "school assessment" or other things.

After our first several appointments with the developmental pediatrician, we submitted several claims to the insurance company, not knowing whether it would be covered as medical or mental health claims.  Astoundingly, the claims were covered as medical claims, at 60%.  It was easier than we thought!  Hooray!  After several more visits, and about $1500 in bills, I submitted another pile of receipts and waited.  And waited.  And waited.  And waited.  And waited.  No check.  No explanation of benefits (EOB).  Nothing.  Seth called the insurance company (it only seemed fair, since it's HIS insurance) and they said, "Oh, those claims SHOULD have been processed, but we accidentally denied them saying that they should have been submitted to EAP for preapproval.  We'll re-process them and you'll receive a check in 2-3 weeks."  Three weeks passed and we heard nothing.  So I called them this time, and I had the most infuriating conversation I've ever had in my life:

Me:  I'm trying to find out the status of these claims.
Them: Oh those claims were denied.
Me:  I haven't received any EOBs.  Can you tell me why they've been denied?
Them:  We denied them because they're mental health claims.  They need to be preapproved by EAP.
Me:  No, my husband spoke to you a few weeks ago and was told that they were mistakenly denied for that reason, but were being resubmitted for approval because they should have been approved.
Them:  No ma'am. These are mental health claims, so they have to be submitted to EAP for preapproval.
Me:  I don't understand... in June you approved a claim with the same CPT Code.
Them:  It doesn't matter, ma'am.  We don't use the CPT code, we use the Diagnosis code.  The diagnosis code on this claim is a Mental Health Diagnosis.  So it needs preaproval by EAP.  
Me:  But the diagnosis code last month was also a Mental Health diagnosis.  
Them:  But last month, the CPT Code reflected a medication check, so it was a medical claim, not a mental health claim.
Me:  I thought the CPT Code was irrelevant?
Them:  What is relevant is whether it is a medical procedure or a mental health visit. 
Me:  Okay, so the CPT code drives whether it is covered or not, then?
Them:  No, if it is a mental health diagnosis, it has to have preapproval by EAP.
Me:  You're not making any sense.  June's claims had the SAME Diagnosis code AND the SAME CPT code as this month.  The only difference is that in June you approved the claim and this time denied it.  Can you explain why?  
Them:  Yes, it was denied because it's a mental health claim.
Me:  No, it's a medical procedure, per the CPT Code.
Them:  No, it's a mental health claim, per the diagnosis code.
Me:  You're not understanding me.  Three weeks ago, my husband spoke with you and you explained to him that these claims were accidentally denied, but that they shouldn't have been.  They were to be reprocessed for approval because they should have been approved in the first place.  What you don't seem to be understanding is that you literally owe me thousands of dollars at this point, which prevents me from continuing to guarantee that I can afford appropriate medical care for my child when he needs it.  Can you at least understand where my frustration is coming from?
Them:   Ma'am, the diagnosis code is a mental health diagnosis code, so the claim needs preapproval from EAP.
Me:  Then why did you approve an IDENTICAL claim in June?
Them:  The procedure code in June was a medical code.
Me:  The procedure code on these claims is a medical code as well.  That's what I've been trying to tell you.
Them:  Ma'am, as I've already told you, the procedure code has nothing to do with whether the claim is approved or denied; the diagnosis code drives whether it is considered a mental health claim or a medical claim, not the procedure code. 

I swear to you, I almost threw the phone across my office.  If it hadn't been the middle of the work day, I might have been driven to drink.  Except that drinking leads to more migraines, and that's no fun at all.

My head spinning with visions of CPT codes, Diagnosis codes, claim forms, and murder plots, I told Seth he would have to take these claims to EAP which is a whole different process including a whole different set of information.  I would do it myself, except that the EAP office is an hour away from MY office and only feet from his office.

Yesterday, my beloved husband went over to the EAP office for me, armed with copies of all our invoices and claim forms.  He had a lovely conversation with the EAP representative, who was extremely helpful but could not process the claims for him.  Why? 

Oh, see, according to the lovely woman at EAP, the CPT code on these invoices is a - wait for it - medical procedure code.  Since it's not a mental health procedure code, it doesn't need preapproval from EAP, so there's nothing to be done on the EAP side.  This is, apparently, something the medical side gets wrong.  Often.

She called over to the medical claims department and explained that she was sending back these claims and that they needed to be processed and approved.  Needless to say, I'm not holding my breath.

Studies show that the stress levels in parents of kids with ADHD are as high as parents of kids with autism.  I believe it, but sometimes I wonder if it's because of the ADHD, or if it's because of the insurance companies.  (It's both)

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57 comments or Leave a comment
marag From: marag Date: October 28th, 2008 04:40 pm (UTC) (Link)
::sends vast quantities of virtual Valium::

You have my complete sympathy, as I've had conversations along those lines many a time!

The best insurance company story actually comes from someone on my flist, who had a batch of claims denied. When she called, she was told the forms were missing a special code. (Let's call it the X code, because I can't remember the stupid name.)

"What should the X code be for this kind of visit?" she asked.

"I don't know," the woman replied, "because that's up to your doctor."

She called the doctor's office and the doctor had never heard of the X code, so she called back the insurance company. "My doctor doesn't know anything about this code. Can you tell me what code you want?"

"We can't tell you what code to put."

"Okay, can you at least tell me where it's supposed to appear on the form? Because there's no space for the X code."

"I don't know."

::headdesk:: I think they specifically pick their customer service reps for stupidity. Really, I do.
estherchaya From: estherchaya Date: October 28th, 2008 05:54 pm (UTC) (Link)
I don't think it's stupidity. I think they train them in giving the run around.
ichur72 From: ichur72 Date: October 28th, 2008 04:52 pm (UTC) (Link)
>> ometimes I wonder if it's because of the ADHD, or if it's because of the insurance companies. (It's both)

Yes, it is. Sending much sympathy. Now that I've figured out that my son's quirks are autistic-type behaviors and not just delightful eccentricity, I am going down the road of developmental evaluations and all that jazz. Trying to navigate it all makes my head spin, and dealing with insurance makes me furious. Our insurance does cover the cost of the developmental evaluation (provided it's done by a pediatrician and not a psychologist). But it covers nothing else. Nothing. Not speech therapy, not occupational therapy, nothing developmental-related. They only pay for that kind of thing if it's needed for physiological reasons, like speech therapy for a kid whose voice box is injured in a car accident. It makes me want to tear my hair out -- or cry, when I think about how much it all might end up costing.
arosoff From: arosoff Date: October 28th, 2008 04:55 pm (UTC) (Link)
Mental health parity is coming in on Jan. 1st, so that might change.
From: black_op Date: October 28th, 2008 05:02 pm (UTC) (Link)
My sympathies.
I'm no fan of beauracracies,
certainly not of those incapable of explaining themselves
concisely and logicly.
estherchaya From: estherchaya Date: October 28th, 2008 07:50 pm (UTC) (Link)
I don't think it's that they're incapable of explaining themselves- I think they do it on purpose. I think that their hope is that most parents will give up pursuing these claims so that they won't have to pay out. At the very least, the longer it takes to pay out the claim, the more interest they make off of my money.
zachkessin From: zachkessin Date: October 28th, 2008 05:06 pm (UTC) (Link)
That dialog mostly put me in mind of "Who's on first" but less funny.
journeytoernie From: journeytoernie Date: October 28th, 2008 05:13 pm (UTC) (Link)
THAT'S what it made me think of. i couldn't remember...
journeytoernie From: journeytoernie Date: October 28th, 2008 05:12 pm (UTC) (Link)
wow. i bet you felt like you were running around in a circle...

Because my favorite thing to do on a Tuesday morning is go see a therapist, or, say, a developmental pediatrician, just for kicks.


our insurance wouldn't cover much from kki, but they did some magical stuff and cut back a lot of the fees that we would have had to pay. like the total bill was something like 2k. the insurance paid something like 15k. and we had to pay $80 because kki did some fancy stuff.

what insurance do you have?
netiimvzaviyos From: netiimvzaviyos Date: October 28th, 2008 05:43 pm (UTC) (Link)


Yep, I can hardly wait for our turn!
(Deleted comment)
estherchaya From: estherchaya Date: October 28th, 2008 07:54 pm (UTC) (Link)
I have the same problem. When I changed my insurance policy from an individual policy to a family policy (by adding the triplets), my policy number changed. But that meant that their first 30 days of life, they were covered under one policy number (at the hospital) and after that, they were covered under a different policy number. So when the hospital passed on their insurance information to various companies, they screwed everything up. Plus, the hospital billed Sam as "Samuel Cohen", but Sam wasn't under the old policy number because he didn't have a name until he was 5 1/2 weeks old - we didn't file his birth certificate information or SSN information until after his bris. So it should have been "Baby Boy Cohen" which the hospital knew. We gave the nurses in the NICU permission to call him Sam, but told them that Samuel should never be recorded in his official hospital record, but they did it anyway.

It created HUGE messes that we're STILL sorting out.
rlitterst From: rlitterst Date: October 28th, 2008 06:43 pm (UTC) (Link)
*Hugs* As Steve said, I feel your pain. Good luck!
estherchaya From: estherchaya Date: October 28th, 2008 07:55 pm (UTC) (Link)
yeah, been there done that. See my response to Steve.
mrn613 From: mrn613 Date: October 28th, 2008 06:57 pm (UTC) (Link)
I am not sure why you think speech therapists are the therapists who treat children with learning disabilies. There is an entire subset of teachers with advanced training in learning disability instruction, such as the Orton Gillingham method. Usually they have to take 30 credits (an entire year of credits) to receive a Dyslexia Teaching certificate in addition to the requirements of their Education or Special Education license.

Honestly I have never been thrilled with therapists who 'diagnose' medical conditions such as ASD, LD, ADHD etc.
estherchaya From: estherchaya Date: October 28th, 2008 07:10 pm (UTC) (Link)
speech therapists are not the only therapists who treat children with learning disabilities. And it obviously depends on the learning disability. Speech pathologists are one of the specialists who treat children with dyslexia in particular. The speech pathologist that we are seeing specializes in pre-reading skills. The speech pathologist who is doing J's therapy is not the same therapist who did his evaluation. That was by design. The speech pathologist who did his evaluation, in fact, does not DO therapy for this kind of issue, by design.

We are currently having a neuropsychologist evaluate J for learning disabilities across the board, but for the moment, we know he has dyslexia at the very least, so we're treating him for that, and so far, it's working - he's already making really good progress.

From: predigested Date: October 29th, 2008 01:35 am (UTC) (Link)
Sigh. This is why, so often, I say to people: "Welcome to Hellthcare!"

I worked for Aetna US Healthcare for 3 years in their customer service (hah!) call center as an analyst. What you have described is par for the course for every day I worked there for some poor schlub who had to call in...
estherchaya From: estherchaya Date: October 29th, 2008 01:48 am (UTC) (Link)
So tell me, do they TRAIN employees to be obtrusive? On purpose? Or is that just an added bonus?
yeishlitikvah From: yeishlitikvah Date: October 29th, 2008 03:19 am (UTC) (Link)
HUGS I marvel at how you can so calmly describe these stressors that would have me running and hiding under furniture hissing at people
kalki From: kalki Date: October 29th, 2008 04:20 am (UTC) (Link)
I can't tell you how much crap we have to deal with insurance as well since my insurance ended 2 weeks after we had the babies. We are being told that we needed a REFERRAL for our babies to be in the NICU. Right. Because it was a planned visit! So it's been back and forth and back and forth.

Don't even get me started on our SSI forms and how many phone calls that has taken.
From: (Anonymous) Date: October 30th, 2008 06:12 pm (UTC) (Link)
Insurance companies are businesses, and as such, it is in their best interest to not give you money, since that makes them more profitable. Ergo, they will structure their bureaucracy in such a fashion as to make it as difficult as humanly possible to give you money. They profit by screwing you over. Period.

This is why I will never trust them as far as I can kick them.

Don't buckle on this one. Make them pay up, whatever it takes. They have no right to abuse people like this.

As for ADHD, I could talk to you a bit about that one, but preferably not in an open channel. :)
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