New Year, New Co-Pays

Insurance Coverage for Occupational Therapy

Ah yes, it’s January first. A day of new beginnings, resolutions, and for a lot of people- a fresh new deductible to meet on their insurance policy.

In the world of pediatric therapy, insurance can drive a parent (and therapist) crazy. First of all, you are lucky if your therapy is covered in the first place. Many policies have clauses that exclude developmental delays, sensory integration therapy, autism, or anything that isn’t an acute injury or illness. For those parents, it’s an out-of-pocket expense of over $100 per session. Ridiculous.

Let’s just pretend that you are lucky enough to have coverage. Great, let’s do this… oh, but wait, you only get 30 visits a year. For most of my clients, that won’t get them where they need to be. So, by October or so, you’re shelling out the cash to keep your child’s spot in therapy or you have to drop out all together. Ridiculous.

Ok, ok, now let’s pretend that you have coverage, and your plan gives you enough visits to get through the year. Hold that thought once again, because it might be likely that your insurance benefits don’t kick in until after your deductible is met. That could be anywhere from a few hundred dollars to a few thousand. Ridiculous.

Paying for therapy seems to become more challenging every year. I have many clients that drop off of my schedule in January because their therapy isn’t covered anymore by their new plan. There are others that simply don’t want to pay out-of-pocket until they meet their deductible, so they delay therapy. Or, I just have to watch as some families struggle to manage their co-pays that rise each year, climbing from $30, to $50, to $70. You know what I think about that… yep, ridiculous.

So with all of these things in mind, I wanted to share some of the best lessons I’ve learned to get the most from your insurance policy:

  • Check out all of the various clinics in your area to find one that you like that also happens to be in-network with your insurance.
  • Find a clinic that is willing to stand battle with you against the insurance company, or at least steer you in the right direction. A company with a staff worker that deals with insurance should be able to give you some assistance.
  • Many insurance companies will simply give you the run around in an attempt to withhold payment, assuming you will give up. If they should be paying according to your benefits, don’t give up. Just keep calling and pestering them. This is a case where the squeaky wheel eventually gets the grease.
  • Ask what your insurance company requires as far as paperwork. Sometimes an additional report or progress note from the therapist is all that is needed to grant coverage.
  • For an insurance plan with many exclusions, sometimes simply filing the claim under a different diagnosis code will get the claim to go through. Check with your company for their covered therapy codes (these include ICD-9 or CPT codes), and then ask your clinic which ones they file.
  • When benefits for therapy visits are combined (i.e. 60 visits for both OT and Speech), then delegate your visits to go towards the most expensive out-of-pocket therapy. Just tell the clinic your preference. I’m surprised by how many parents don’t do this.
  • Check to see if your coverage offers a “BOGO” option. (Ok, it’s not called that, but I like the sound of it better than a “59 CPT code modifier”) For example, some plans only require one co-pay if therapy services occur on the same day. All it takes is a little scheduling to save a lot of cash.
  • Tell your clinic about ALL of your child’s official diagnoses. Don’t be shy here.  PDD, autism, developmental coordination disorder, adding any of these diagnoses may allow a claim to slip through.
  • Search the web for grant money. It’s out there, you just have to look to find it, and then work to submit all the paperwork. For some programs, the main requirement is that you meet the income standards for your family size.  (I’ve seen families get as much as $4500 through the United Healthcare Grant to cover OT).
  • If all else fails and you have to pay out-of-pocket, be smart about it. Some parents come to me and say, “I’ve saved up enough money for 8 sessions. What can we get done in that amount of time?” I gotta say, I can’t help but admire that honesty. In those situations, I’m forced to prioritize, and I know I have someone who is willing to follow through on all of my suggestions. Don’t let your therapist tell you nothing can get done in a short amount of time. At least a child can begin to head in the right direction.

Whatever the new year brings you, let’s hope it includes headache-free insurance with lots of benefits! Cheers!


About TheAnonymousOT

Pediatric Occupational Therapist
This entry was posted in Insider Information, Lessons Learned, Occupational Therapy and tagged , , , . Bookmark the permalink.


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