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)