For those of you following our battle with Blue Cross and speech therapy coverage, we have a final answer.
We appealed through the State of NY and they later sent us a letter saying they were sending all of the info to an “impartial” 3rd party in Massuchusetts for review by medical professionals. I really thought this was going to work in our favor and this was all going to end well. I was shocked to receive the final denial from them along with some notes from the three professionals who reviewed the case. I was shocked especially to see the notes from a SLP stating services weren’t necessary. I just was blown away by this, especially when considering his neurological diagnosis and our supporting letters from the neurologist! I am convinced the insurance company must have these “professionals” in their back pocket because there is no good reason for a denial. My neurologist was even very shocked, saying she had never seen anything like this before and that it didn’t make sense.
Blue Cross is SO SO SO lucky that we are fortunate to have a fantastic SLP at school and that they added more sessions to compensate for this denial. Otherwise I would come after them so hard they wouldn’t know what hit them. This is all despite in their letter saying, “this is final, please don’t contact us on this matter again”. We are dealing with so much right now outside of his speech that I had to let this go. Like I said, they were lucky. I can make a huge pain in the butt of myself if the cause is right. But Blue Cross is permanently on my s*%t list.
I called BCBS the other day wondering the status of my appeal. He said it was processed and mailed, but he couldn’t tell me the decision. Considering the next day I got a big fat envelope saying “NO”, “NOPE”, “DENIED”, I’m not surprised he didn’t share the decision with me. (there were probably also notes on my file to fear for your life if you cross me or my son, because I will be your worse nightmare :D )
I really, really thought based on the appeal letter I wrote and the supporting letters from the neuro and SLP that we would win. I also thought they couldn’t deny his cute little face considering I included a photo of him too! Cold, cold hearts over there at Blue Cross. It was kind of like waiting for a college acceptance letter. When it was so big and fat I momentarily got excited…then I thought, wait, what could be in there? Why of course! It’s pages and pages of complicated information in nonsensical language about how if I don’t agree with them I need to take it up with New York because they are over it, and me, and I need to get a lawyer to understand it all.
I called the neuro’s office and they agreed to write another letter on our behalf including Henry’s new diagnosis, and I’m hoping the genetic anomaly card will win us this hand. Who knows. It will take another month minimum to get it figured out. Meanwhile Henry is getting maybe 2 speech sessions a month and the pressure is on to practice more at home. The fear of regression is looming.
I think I use more of my cell minutes on the phone with Blue Cross than I do with my friends, and I’m over it. I’m angry. It’s ridiculous.
I have had issues with them in the past regarding Henry’s coverage for therapy. I have made appeals and thankfully won. I was gearing up as we approached the cap of our 45 visits per year that were allotted, and assumed that was the next battle on my hands. I was preparing.
I was not expecting full denial of coverage for him based on the fact that he is now attending preschool. I have heard of this happening, foolishly I didn’t think it would happen to us. I had already fully explained the necessity of one on one intense and consistent private therapy for Henry…and I seemed to convince them. Now their view is that the school should be responsible for all of his therapy moving forward. We have a lovely and well respected speech therapist at his school, but he has a great connection with our private SLP and has made such progress with her and I don’t want to lose momentum. Why would we change something that is working? Why is it so hard to get our kids what they need? It makes me nuts.
I contacted BCBS again to go through the details of the appeal process and then I contacted CASANA for some guidance in drafting a letter. They were kind enough to share a sample appeal for a similar situation and I modified it for our case specifically. I got amazing letters from our SLP and neurologist to support the appeal and I included the cutest picture of Henry I could find. Now we are waiting fingers crossed.
ps. I have another letter to BCBS stating how I really feel, holding nothing back. It was never sent of course, it’s something that is drafted only in my head and replayed every time I have to deal with their idiocy. I thought I would share it here, but then thought the foul language might offend :)
I’m not sure what we are going to do. Despite attempts to appeal to my husband’s employer for better insurance coverage for 2012, nothing could be done. We are stuck with the same 45 visits per year, which include speech, OT and PT combined. Seeing he needs all three, this coverage just might get us through March.
In good faith, my husband’s employer is going to try to help a little financially with these added costs. I think they feel bad about the limitations of our insurance and empathize with our situation. I appreciate that, but it doesn’t put us in a much better position. The hard part is whenever a positive change comes financially and we think we can catch up, or even get a little bit ahead, we get hit with some other financial bleed. Therapy will be taking all of our money beyond our basic bills. We would do anything for Henry, and it’s worth it, but I have to say it just doesn’t seem fair. I know many families with children with special needs fight the same battle. I will continue to fight our insurance company and see what happens, but I don’t anticipate any changes there. I have also applied for a couple of grants and I’m keeping my fingers crossed. This last trip to Kaufman was worth it, but wiped us out. I’m saying prayers that it will all work out.
It’s shocking. I spend a lot of time cursing Blue Cross Blue Shield and health insurance companies in general. But shockingly enough I got a tidbit of good news today from our SLP!!
After finding out Henry may need additional OT outside of early intervention as well as PT, I freaked out. As it is, we only get 45 visits per year, and OT, PT and Speech are all under that 45 visit umbrella. We also have to beg for 8 or so visits to be approved at a time within that 45 count.
My SLP said some insurance companies count a day as a visit…as in he could have PT, OT and Speech in one place on the same day and it would count as one and not three. (of course there are still 3 separate $25 copays that add up, but it’s better than $180 a session). This sounded too good to be true, I mean, this is BCBS we are talking about here… but she looked into it and we qualify for that option! Awesome!!!! Now we just need them to approve it…I already see appeals in my future! I’m ready!