Sorry, This Service Isn’t A Covered Benefit
You take your child to the pediatrician and they want you to have your son/daughter evaluated for occupational therapy and they hand you a list of recommended providers in your area. You check Google Reviews, look at their social media, check out their website, ask your other parent friends for recommendations and you settle on a therapy clinic to call. You call them, they take down all your information, make the appointment and then the billing department calls you a few days later to inform you that your insurance plan does not cover this service. What?!?! You have medical insurance, doesn’t that mean anything? Now, what are you supposed to do? No worries, here are a few things that will help you advocate for your child.
Call the member services number on the back of your insurance ID card. Ask them to send you a copy of your policy and where it talks about this service and what the coverage actually is. Some insurance plans will only cover rehabilitative services (therapy needed as a result of an illness, injury or birth defect). If they are stating there is no coverage, see if they will authorize an evaluation of this service so you at least know where your child stands developmentally and if there is a diagnosis. Most insurance plans will cover an initial evaluation.
Have your child’s pediatrician write you a letter of medical necessity. This is a letter that providers write to show the benefits of therapy and how your child’s quality of life will be affected if therapy is not received. This can be sent to your insurance company as part of the proof you may need to get this service covered.
Ask for a Peer to Peer Review. This is a conversation between your provider and a medical reviewer (usually discipline-specific) at your insurance company. This helps the two entities come to an agreement on a realistic plan of care and/or time frame for your child to receive the treatment they need.
Go talk to your HR department about your benefits. Explain to them that you need this service for your child and it is not a covered benefit at this time. This may help influence your employer’s decision to choose a different insurance company or additional plan options for their employees. It may not help you in your current situation, however, it could change the insurance options available when re-enrollment comes around (usually in October).
If your child has been diagnosed with Autism, I have great news for you!! Some insurance plans have a special clause in their policy written especially for Autism. This clause states that there are no limits on the number of therapy visits your child can attend in a calendar year. Make sure you ask if this is a benefit with your insurance company (some smaller companies are not able to provide this benefit)!
Wilson Pediatric Therapy’s billing staff is happy to help you navigate your insurance issues, however, please know that it is ultimately up to the member to know the limits of their insurance coverage. If your insurance does not cover therapy services, we do have private package plans available if you still want to pursue therapy with us. Please email billing@wilsonpediatric.com if you have specific questions about your insurance benefits or payment options.
If you feel your insurance company has wronged you in some way, you can always reach out to the Kentucky Department of Insurance toll-free at 800-595-6053 and ask to speak to someone in Consumer Protection. Or you can visit their website at insurance.ky.gov for more information.
