Denied insurance claim for speech therapy, for swallowing
July 28, 2016 8:00 AM Subscribe
Blue Cross Blue Shield of Illinois is refusing to cover speech therapy for my toddler's swallowing disorder. They say they only cover speech therapy for speech problems. This seems insane. What next?
Nanopanda, now 2.5, had a real shitty winter last year: three multi-day stays in the ICU, with prolonged hospital stays. Bronchoscopy & bronchial lavage confirmed chronic aspiration, most likely part of a feedback loop with her prolonged episodes of respiratory distress. After a year of drinking only thickened liquids, her pulmonologist felt it was appropriate to begin weaning her off of the thickeners this spring. Unfortunately, during that year, she lost the ability to drink thin liquids without choking, so we began seeing a speech therapist to teach her to drink safely. It's been going very well, actually.
Except that BCBSIL is denying the claims and telling me they *only* cover speech therapy for speech related problems. This seems insane, since speech therapy is generally accepted to cover both speech and swallowing. Swallowing is not mentioned anywhere in the plan, although it does say "Speech Therapy does not include educational training or services designed and adapted to develop a physical function". Which doesn't sound promising. Blue Cross says to ask the provider if they can resubmit the claim under a speech related condition, but that seems like it would be very difficult to do, since she has no speech problems, only swallowing problems.
However, in this document (pdf) which, granted is for the HMO, but nonetheless has much more detail, it says "Speech therapists guide the improvement of speech and also help diagnose and treat infants and adults with swallowing disorders." And the Blue Cross plans in most other states seem to agree.
I understand that every state is different, but the swallowing thing seems pretty standard. And we've never run into weird coverage denials before, so I'm new at this. It's especially frustrating because this is a serious medical issue that could very well be the difference between staying out of the hospital, and another trip to the ICU. We're saving the insurance company money here! I called the speech therapy office, but they haven't called me back.
I am looking for tactics, advice, reassurance, decision trees, personal experience, etc. Basically anything besides "you should have checked more carefully first", given that that ship has sailed. Ironically, our state's Early Intervention declined to admit her into the program because "it's such a cut-and-dried medical condition that you should just go through your insurance." Sigh.
Nanopanda, now 2.5, had a real shitty winter last year: three multi-day stays in the ICU, with prolonged hospital stays. Bronchoscopy & bronchial lavage confirmed chronic aspiration, most likely part of a feedback loop with her prolonged episodes of respiratory distress. After a year of drinking only thickened liquids, her pulmonologist felt it was appropriate to begin weaning her off of the thickeners this spring. Unfortunately, during that year, she lost the ability to drink thin liquids without choking, so we began seeing a speech therapist to teach her to drink safely. It's been going very well, actually.
Except that BCBSIL is denying the claims and telling me they *only* cover speech therapy for speech related problems. This seems insane, since speech therapy is generally accepted to cover both speech and swallowing. Swallowing is not mentioned anywhere in the plan, although it does say "Speech Therapy does not include educational training or services designed and adapted to develop a physical function". Which doesn't sound promising. Blue Cross says to ask the provider if they can resubmit the claim under a speech related condition, but that seems like it would be very difficult to do, since she has no speech problems, only swallowing problems.
However, in this document (pdf) which, granted is for the HMO, but nonetheless has much more detail, it says "Speech therapists guide the improvement of speech and also help diagnose and treat infants and adults with swallowing disorders." And the Blue Cross plans in most other states seem to agree.
I understand that every state is different, but the swallowing thing seems pretty standard. And we've never run into weird coverage denials before, so I'm new at this. It's especially frustrating because this is a serious medical issue that could very well be the difference between staying out of the hospital, and another trip to the ICU. We're saving the insurance company money here! I called the speech therapy office, but they haven't called me back.
I am looking for tactics, advice, reassurance, decision trees, personal experience, etc. Basically anything besides "you should have checked more carefully first", given that that ship has sailed. Ironically, our state's Early Intervention declined to admit her into the program because "it's such a cut-and-dried medical condition that you should just go through your insurance." Sigh.
Have you talked to your speech therapy provider about this? In my experience with getting similar things covered, the people in provider business offices usually have a lot of experience with how to deal with insurance plans so treatments will be covered.
I haven't dealt with speech therapy, but in my other experience, getting the provider to re-submit claims so they get covered is not that big of a deal. Providers know insurance is ridiculous and they are usually sympathetic about how to finagle a claim so it meets the criteria, without being dishonest. They're on your side way more than the BC/BS people are.
Hang in there!
posted by pantarei70 at 8:10 AM on July 28, 2016 [6 favorites]
I haven't dealt with speech therapy, but in my other experience, getting the provider to re-submit claims so they get covered is not that big of a deal. Providers know insurance is ridiculous and they are usually sympathetic about how to finagle a claim so it meets the criteria, without being dishonest. They're on your side way more than the BC/BS people are.
Hang in there!
posted by pantarei70 at 8:10 AM on July 28, 2016 [6 favorites]
Response by poster: Nanopanda had a swallow study done after the second ICU admission which was inconclusive. The speech therapist she has been seeing is preparing for a follow up swallow study soon, prior to clearing her for thin liquids.
However, the bronchial lavage results (obtained after the third ICU admission) were strongly positive for aspiration. She also had two pneumonias that developed during her first and third hospital stays that were thought to be the result of aspiration.
Also she had multiple episodes of choking on thin liquids early this spring as we thought about transitioning off thickeners, and at her speech evaluation, the therapist noted that she was unable to coordinate breathing and drinking. That's what we've been working on, with notable progress.
posted by telepanda at 8:10 AM on July 28, 2016
However, the bronchial lavage results (obtained after the third ICU admission) were strongly positive for aspiration. She also had two pneumonias that developed during her first and third hospital stays that were thought to be the result of aspiration.
Also she had multiple episodes of choking on thin liquids early this spring as we thought about transitioning off thickeners, and at her speech evaluation, the therapist noted that she was unable to coordinate breathing and drinking. That's what we've been working on, with notable progress.
posted by telepanda at 8:10 AM on July 28, 2016
Enlist your physician and your speech therapist to help with this. You're right that swallowing is a typical intervention for SLPs, and in my experience is the one they're usually happier to cover (vs. speech therapy which is a "developmental problem" and therefore something they won't touch-I have some feelings about that). Anyway, it is something providers have to deal with all the time. They can submit an appeal and escalate for you.
posted by goggie at 8:12 AM on July 28, 2016 [3 favorites]
posted by goggie at 8:12 AM on July 28, 2016 [3 favorites]
Can they rebill under a different code?
posted by bq at 8:13 AM on July 28, 2016 [3 favorites]
posted by bq at 8:13 AM on July 28, 2016 [3 favorites]
I work a lot with insurance claims etc, have the office file an appeal and have them write a letter of medical necessity. A lot of times that's all it takes to get coverage.
posted by Quincy at 9:04 AM on July 28, 2016 [1 favorite]
posted by Quincy at 9:04 AM on July 28, 2016 [1 favorite]
Is nanopanda's insurance through your or your husband's work? If so, one additional avenue is to go talk to HR and tell them you're getting a denial for a medically-necessary treatment for your kid, and you'd like some help looking through the plan documents to understand whether what they telling you (about speech pathologists not be covered for medical swallowing issues) is indeed written into the insurance policy.
Depends on how great/sucky your HR department (or your husband's HR department) is, but my experience with a totally annoying billing snafu a few months ago was that my husband's company was ALL OVER the insurer to fix it, and they had a lot more leverage than I did alone.
posted by iminurmefi at 9:56 AM on July 28, 2016 [1 favorite]
Depends on how great/sucky your HR department (or your husband's HR department) is, but my experience with a totally annoying billing snafu a few months ago was that my husband's company was ALL OVER the insurer to fix it, and they had a lot more leverage than I did alone.
posted by iminurmefi at 9:56 AM on July 28, 2016 [1 favorite]
Your provider's billing office will have SO much more experience dealing with this. Have you contacted them and asked them to appeal the insurance company's decision? That would be my very first step. My guy has a chronic medical condition and appealing denials is a normal thing for us. Don't stress. You may have to have it run through as a physical therapy service. Ask the speech therapist's office, they have been down this road before.
posted by PorcineWithMe at 10:14 AM on July 28, 2016
posted by PorcineWithMe at 10:14 AM on July 28, 2016
I work at a hospital, and I deal with insurance companies and handle referrals/ authorizations/denials. My advice is to contact your provider and have them appeal the decision. It could be that they have to supply better documentation, or more specific codes, or request a review from BCBS's medical director. Your provider has likely seen this before - they have, or should have, staff to handle this.
posted by DrGirlfriend at 10:50 AM on July 28, 2016
posted by DrGirlfriend at 10:50 AM on July 28, 2016
Enlist your physician and your speech therapist to help with this.
This, this, this!
If it's on record as being necessary, they KNOW they better pay it. If it's just you requesting, they'll stall you off until the cows come home.
posted by BlueHorse at 11:26 AM on July 28, 2016
This, this, this!
If it's on record as being necessary, they KNOW they better pay it. If it's just you requesting, they'll stall you off until the cows come home.
posted by BlueHorse at 11:26 AM on July 28, 2016
This thread is closed to new comments.
posted by pintapicasso at 8:03 AM on July 28, 2016