Wednesday, February 25

What works for us Wednesday

Understanding insurance benefits is no small feat. But when you have children with medical needs and developmental delays, it's an understatement to say that you need to read your benefits. You need to know how to 'work them' to your advantage. Many insurance companies post their benefits online and also allow you to read EOB's thru the internet (explanation of benefits) which greatly help ease reviewing ALL the claims.

We recently added speech therapy services thru a private SLP center (connections) once week on top of the speech and feeding therapies that we also receive from the 0-3 yrs program. Since we have three forms of insurance now, we learned a new rule.... since medicaid is our third form of insurance for Tommy they will only pay on claims that our primary insurance feels are allowable. And that is where our problem started, this private SLP was not in contract with our primary insurance.... no one was going to pay for speech therapy to them. So, we have spent the better part of two weeks stuck in a process called filing a "Gap Exception".

We asked for 40 visits for Liam for speech and the same for Tommy for the remainder of the year to this private SLP. Which would get us to the date that we start preschool. (Whether that is with the school district special education preschool or through a private Christian school we still haven't decided, an important question though as Wa State discriminates against providing State paid therapies (OT, PT, Speech) at a religious school, big bummer and is greatly influencing our decision). But back to the story, the Gap Exception has been filed and now the waiting game.

What worked for us in this process of adding a new service is to know our benefits and to "prime" our pediatrician that they may be asked by our insurance (and he was) about the 'need' to access speech therapies. A few simple phone calls ahead of time saved delays later. With a diagnosis like Down syndrome for Tommy (and Hirschsprung's disease).... and Liam having apraxia of speech I would have thought it a simple approval and no need for a pediatrician's involvement. And also to work through our care coordination department in our insurance company on getting all of the correct forms filed. Daily pestering phone calls to the insurance company due no good, but bring this mommy GREAT JOY.

Fingers crossed we get half of what we asked for. Which in the world of DD services is a high expectation...... unfortunately.

Tommy Adventures