Friday, August 31, 2012

Insurance Hassles



We have been having some hiccups with Allie's insurance lately, all of which makes us nervous. We have a HMO that up until a couple weeks ago was fantastic. We have unlimited therapy, they haven't balked at all the specialists that we have seen, didn't hesitate to cover her $90,000 for a month of seizure medication, paid for her head re-shaping helmet (which we were told insurance companies rarely cover), and have been free flowing with the referrals to try different types of less-traditional therapy programs (constraint and aquatic).

However, they recently got a pediatric neurologist on staff and want us to meet with her instead of the pediatric stroke specialist who we have been seeing for the past year at the Children's Hospital. The pediatrician said that it is totally possible that the neurologist will recommend that we keep seeing the Children's group, in which case this won't be an issue at all, but the uncertainty is unnerving. We have an appointment with the new neurologist on Sept 17 and our plan is to make Allie's diagnosis seem as scary and possible so that we get bumped back to the specialist. I am hell-bent on sticking with our neurologist, who has been incredible throughout Allie's care. If all is going well, we will keep meeting jointly with her and Allie's physiatrist every 6 months. It is so cool getting two perspectives at the same time and having one less doctor's appointment. If things are not going well, the neurologist responds to email in the middle of the night and organizes brain storming sessions with other doctors to try to figure out what we can do. I love her.

A few months ago, we ordered a Benik hand splint to help Righty be a little more engaged. Allie has a tendency to fist her hand when she is trying to do something that requires concentration and this fisting gets in the way of her actually using her hand.  This order was placed by Allie's constraint occupational therapist and we were told that it could take a few weeks to get processed. Well, the order just evaporated with the company and we had to resubmit it after over a month of waiting. This order was then denied by our insurance because the provider that the OT used was out of network. Allie has a case manager through our insurance whose job it is to ease the communication between the insurance company and the providers (you know your diagnosis is serious when they bring in a person just to help you manage care). I called up the case manager and she entered a new referral for the splint. Over a week later the splint was denied again because our insurance benefit is for "durable medical equipment" and the splint is made of mostly neoprene, which is deemed non-durable. The case manager is making a case that since there is an aluminum support in the splint, it should count as "durable". The splint costs a couple hundred dollars and we probably would have just paid for it out of pocket if we knew it was going to be such a fight.

Neither of these things are a deal breaker yet (the neurologist may be but we are withholding judgment until after our appointment) but it does raise some red flags. Our open season for changing insurance plans is in November so we may look into our other options just to be informed. I hate messing with an (almost) good thing.

2 comments:

  1. I think you may have asked this over on HemiKids already, but the Benik is actually only around $50 if you just pay out of pocket.

    ReplyDelete
    Replies
    1. Thanks, Torey! I called Benik and they said that with all the modifications that Allie's OT wants, the splint will be $160. We're appealing the denial out of principle since it is likely that Allie will need similar "non-durable" items in the future.

      Delete