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Will health insurance still pay for my baby's doc band if we stop early?
June 26, 2014 5:09 PM   Subscribe

The provider of my baby's flat head fixing helmet submitted an insurance claim but it has not yet processed. If we quit treatment, will the provider tell the health insurance company? Will we have to pay the full amount out of pocket?

After months of going back and forth, we got little echo (one year old) a doc band (helmet) to help correct her plagiocephaly - she has a flat spot on one side and a corresponding bulge on the other. Numerous doctors have told us since she was two months old that it would correct itself, and it has gotten better, but it is still quite noticeable. Our doctor wrote a letter for us, and my health insurance company says they will pay for 80%. The helmet company says it takes about a month for the insurance claim to go through. It's been over a week and little echo is not adjusting to her helmet and we have some concerns with it (like I actually think it is flattening her forehead. The front of her head is perfect, we don't want it to change). She's also not sleeping well in it, and it's SO hot.

Anyway - if we decide not to go ahead with treatment, and the claim was already submitted, is it possible that the provider will communicate this to the health insurance company and we will instead have to pay out of pocket? Does anyone have any experience with this sort of thing?
posted by echo0720 to Health & Fitness (12 answers total)
 
Call your health insurance and ask them. Discuss your concerns and ask them what happens if you decide to discontinue treatment. Then make a decsion.
posted by Ruthless Bunny at 5:20 PM on June 26 [1 favorite]


So the helmet company doesn't bill your insurance directly? Are you currently out of pocket for this helmet and awaiting reimbursement?

A month to process a claim is about right. If it is paper, maybe add a few weeks.

You got verbal confirmation that you are responsible for a 20% coinsurance, and that this device is a covered expense (hopefully with a billing/diagnostic code). Your claim should still be valid because it is against an expense that was already incurred. People could flush their antibiotics down the toilet instead of taking them, and the insurance wouldn't want their money back.

Are you getting several graduated helmets made? Are they already made? I would call your insurance to be sure, but if the service provider bills you for this, and it is a covered expense, you will be reimbursed for it regardless.
posted by fontophilic at 5:29 PM on June 26


Fontophilic, to answer your questions:

It's just one helmet and we already have it.

The provider did bill insurance directly, I just had to pay the 20%. I got an email from the provider saying that they submitted the claim and that the insurance company would probably send me a letter asking for supporting documentation (the letter from my doctor). The helmet company said they would submit the documentation and I don't need to do anything.

I'm worried that if I call the insurance company, then they will drop the claim. Is that too paranoid?
posted by echo0720 at 5:39 PM on June 26


I'm worried that if I call the insurance company, then they will drop the claim. Is that too paranoid?

Yes, that's a bit paranoid. But before you do that, when is your next doctor's appointment? Find out what the doc thinks first, s/he may say, "Yeah, this isn't working right, let's forget it," in which case, you're done, he gets paid, it's yet another thing we tried that didn't work out. Similar to a med you get a bad side-effect from or a piece of medical equipment that doesn't fit correctly.

But you should be able to talk to your insurance and ask questions. Don't tell them you're stopping treatment, ask them what would happen IF you stopped treatment.
posted by Ruthless Bunny at 5:45 PM on June 26


The doctor's office is going to be your resource here, I think, more than the insurance company. If the office is billing the insurance company, they want and expect to get paid by them. It seems unlikely to me that they would tell the insurance company something that would then make them have to go after YOU for the cash (getting money from individuals is so much harder than getting it from the payers).
posted by ThePinkSuperhero at 5:52 PM on June 26 [2 favorites]


I'm so sorry to threadsit, but I wanted to clarify that this is not a doctor's office, it's a medical device company who sells these things, so they're going to urge me to keep going with the treatment (next appointment is in a week and a half). Although maybe The PinkSuperhero is right and they won't care because they are still getting money from the insurance company.
posted by echo0720 at 6:13 PM on June 26


I would think that this is basically like getting any other prescription medicine filled; the insurance pays for its share of the cost of the prescription regardless of whether you take the pills. Unless you're returning the helmet for a refund, your insurance company shouldn't care that you aren't using it on the child.

If you're trying to get out of paying the 20% coinsurance on the helmet, I think that ship has sailed (unless, of course, you can snag that refund, in which case you'd also call up the insurance company to cancel the original claim, or ensure that the provider refunds the insurance company as well).
posted by Aleyn at 6:53 PM on June 26


this is not a doctor's office, it's a medical device company

You're reshaping her head without medical supervision?
posted by JimN2TAW at 7:50 AM on June 27 [2 favorites]


Talk to your pediatrician about your concerns. If she helped you select the helmet and get insurance coverage, I'm sure she will want to help monitor the progress. I wouldn't be starting and stopping without consultation with your medical provider. If the doctor agrees that you shouldn't use it anymore, I'm sure that you will be off the hook in terms of needing to verify correct usage for insurance coverage.
posted by barnone at 12:37 PM on June 27 [1 favorite]


JimN2TAW - my child's pediatrician referred us there, and it is staffed by trained orthotists and therapists. Obviously there is medical supervision. Thanks the implication that I'm a terrible parent, though, you're a peach.
posted by echo0720 at 3:53 PM on June 27


I gave my answer in the form of a question, which made it unclear and unhelpful. I'm sorry if I added to your stress.

I think your question, about insurance reimbursement, is premature.

You said that the medical approach was unsuccessful, so your doctor referred you to the medical device company. You said:

this is not a doctor's office, it's a medical device company

You didn't mention that any doctors were still involved, I guess because it wasn't relevant at the time. The question indicated only that they sell medical devices. It wasn't indicated that they offer therapy as well.

My answer should have been what Barnone said just above. At every step, a trusted professional should be guiding you and answering this type of question for you. Again, I'm sorry I added to your stress at this difficult time.
posted by JimN2TAW at 2:28 PM on June 28 [1 favorite]


Thank you for the clarification and I apologize for my lack of clearness and the bitchy reply. We've decided to keep going with the therapy as my daughter has adjusted a little better and the insurance payment already went through so if we do decide to stop, no issue with money. Thank you everyone.
posted by echo0720 at 11:28 AM on July 20


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