Long Term PT/OT not covered by insurance

[marleneross]

Has anyone ever heard of an insurnace company not covering PT for a Long Term Injury?

We changed our insurance in July, and received a notice that they will not be covering our daughters PT, it states that they do not cover PT for injuries that will need to receive services over 60 days. It also has something down that the type of PT is experimental and not Required. I have my employeer looking into our other policies at work along with the details of the current policy I am on. It states that we can appeal the rulling, but if the policy says they don't I am not sure if it is worth it.

We are very lucky that we currently on EI, but not sure if she will qualify at you 1 year appointment when they will retest her, she really only qualified this time beacuase of her tortticolis and tracking issue due to it. The county is currenly billing the insurance company for the services, I am glad we are getting this worked out now before I have to pay out of pocket for each vist.

Any advise is appreciated.

Marlene - Mom to Sammy (4) and Lindsey (10 months)

[mamaofsix]

Hi Marlene,

We have had battles with our insurance company since Cameron was born- although tiring, each one we have won. Our bp specialists have written letter's on Cameron's behalf stating the need of continual pt/ot, I have written letter as well as his therapists. Get plenty of documentation from your doctors, therapists and your own letter and appeal their decision. Our therapists now obtain approvals for us. They approve visits for us on a 3 month basis.

Is she getting therapy at a hospital or local pt/ot center?

[Kath]

My insurance told me I was cured! When I protested they person I spoke to,on the phone, said that it was as good as it gets. Thanks goodness I was already on UBPN and knew what I had to do... I asked if he was a physician he said he was a PT... My next question was how did he know I was cured if he never examined me and how could he overrule a neurologist?

He told me I could get PT but if they put it was for Erb's Palsy... I had all the treatments I could get. So they don't write Erb's Palsy. I still need PT because secondary issues cause my back to be off balance or my arm, neck to tighten up but they no longer put it's due to Erb's Palsy.

Don't give up the battle because we were all supposed to be bilateral and if we are not we have deficits. I know EI drops many children because they have no mental limitations or can do things one handed. We are not supposed to be one handed and doing things one handed take a toll on the body. All children are two handed until injured and they (two handed) can function at a quicker level then we can do. Therefore, bpi children need extra time to dress and help with many things when they are young so all the PT/OT they can get is important. The goal should be to prevent overuse of the uninjured arm and gaining strength in the obpi arm. Learning better compensatory movements during OT could prevent many of the secondary injuries older adult/obpi suffer from.

[F-Litz]

If you could go with an insurance policy that handles insurance better then switch.

If you can't, one way around it is different diagnoses for each thing you are working on. It can be VERY specific. We just added one diagnosis after another -- bpi is too general a diagnosis. Then once the amount of sessions were done for that dianosis we were able to appear one time to get one more batch and after that we had to switch the diagnosis.

Good luck. The absolute worst part of dealing with this was all the fighting I had to do with insurance. You're not alone with this, that's for sure.

[marleneross]

We have Lindsey's 1yr evaluation for Early Intervention today, and as we fiqured she is being realesed from EI for PT services. We are going to have her tested for OT next week, but most likley we will not qualify either. I don't understand, you would think these programs would be happy that she is progressing and is not falling to far behind and would want to keep an eye on it vs. dismissing it. Our PT will want to still see her about once a month which we will be paying cash out of pocket as the insurance will not cover. Beyond that we will see if we can get the insurance to cover the OT on a short term basis, as it will really add up paying for therepy out of pocket.

Thank you for letting me vent for a few minutes.

Is there anyone else that has dealt with EI in NY?

Thanks,

Marlene

[claudia]

We lived in NY, on Long Island, until 16 months ago. Juliana is now 11 1/2, so we were long past EI. However, used EI very successfully for over 3 years. Understand, that although there are guidelines, your county administers it. Nassau county was a generous county. NY County (NYC, Bronx...) was not so generous and I had friends there who were fighting like crazy. Your first advocate is your case worker. If he/she is on your side you will have an easier time. The next is the county admin for the program. Both were very helpful in Juliana's case. We also signed paperwork (remember, a decade ago...) that didn't allow the county to bill our insurance company. I'm not sure they do that anymore. So, for the first chunk of EI that we used, it all came from the county's coffers. Then they started billing the insurance company. (Just a note here: when we settled our legal case, our insurance company wanted us to pay back not only the non EI stuff, but the EI stuff they paid for...)

ALL Early Intervention/Birth-Three programs are under assault due to decreased funds. Municipalities are not bringing in the cash they used to and EI is an easy place to cut. Here in South Carolina things are a MESS! And parents are freaking out.

As for stuff not being covered... Insurance companies make money by NOT paying for things. Get used to fighting them. Find out the system they use for appeals and start appealing. Make a big nuisance of yourself. Say this over and over: "May I please speak to your superior?" Call over and over. Take everyone's name down. It is terrible, but do it. Set aside time each day to do this.

We also used the end run of new diagnoses. You see: according to insurance companies bpi don't need surgery, they are cured by OT/PT. But only 6 weeks and then (magic!) you are cured!!! laughing yet...

bottom line... it just takes work.

good luck.
claudia

[Carolyn J]

Marlene,
Be STRONG and keep Appealing UNTIL!!! The more times uyou appeal the better chance of winning in your childs favor. Insurance Companies count on parents getting discouraged and just dropping the cause; that's why they do what they do. Even challence your County if they denie services for IE. This all prepares you for the Educational Systems for the years ahead. Welcome to the World of Advocacy we all never deserved. Come here as often as you want to VENT, Advocacy not easy. We here, understand instantly and Care about you. You are a "Warrior Mother", Marlene. BUT please take care of yourself with rest, breaks and occasional Spa Days. You cannot give(read calm for your child) what you Mothers don't have....[I did it the WRONG way & I don't want that for you OBPI Mothers.]

Hugs all around,
"Bossy Gramma" Carolyn J
LOBPI/72++

[KPC's mom]

Does your state have a program that helps with costs? We live in Michigan and get Michgan special health care services. We have to pay in each year, based on our income. This year, it's $10/month. They help pay medical care if it's related to his arm. It pays the co-pay for his therapy & also picks up the whole cost when we max out our visits for the year. My insurance pays for therapy, but limits to 20 visits per year. After Kaiden had surgery, he was going to the OT 3 days a week and the state covered it all. This program is totally separate from the early intervention program he was in, but aged out at 3. That program gave him therapy, but only until they said he met the goals they set for him & they greaduated him out of the therapy.