Developmental disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a person’s lifetime. (cdc.gov)
Developmental Delay Exclusions
Many children with speech and/or language disorders without a related medical diagnosis from a physician are considered to have “developmental delays”. Many insurance plans specifically exclude (do not cover) speech therapy for developmental delays. This means that speech therapy is the patient’s financial responsibility. We have found that often there is a medical condition that supports the “medical necessity” of the therapy, which this insurance will cover. There are also many insurance plans that specifically state that speech therapy for a developmental delay IS COVERED.
There is a medical diagnosis from a doctor as to why a person requires speech therapy that is reviewed by the insurance company. If something is NOT medically necessary, then the insurance company has determined that the condition is not covered under the insurance policy.
Letter of Medically Necessary (LOMN)
An insurance policy may require a LOMN before services are approved. This letter must come from your child’s medical doctor. It should contain a medical diagnosis as well as a statement that “skilled therapy services are medically necessary due to the _______ condition”. The condition should be stated in both words and diagnosis codes (ICD 10 codes).
Some insurance plans only cover therapy when it is to “restore” the patient to a condition he/she was in prior to having an injury or illness. For children, a restorative policy essentially denies them coverage. If you have a plan that specifies that speech therapy is only covered to restore a condition, then speech therapy will only be covered if the patient HAD normal speech and language and LOST IT due to some illness or injury.
Some insurance plans require us to obtain authorization before we can provide the service to you. In this case, we send our evaluation report to your insurance company. Your insurance company then determines if the service is covered under your plan. If so, the insurance company will issue to us an authorization for a specific number of sessions to be used within a specific time frame. The authorization ends when you use up all the sessions or reach the end date, whichever comes first. We can extend the authorization by calling the insurance company if we have come to the end date but still have sessions left. We can also request additional sessions by submitting a progress report that documents that more therapy is needed. When insurance requires authorization for therapy, any therapy that takes place without a valid authorization in place will not be covered by insurance and is the financial responsibility of the patient.
Some insurance plans will allow us to obtain a courtesy pre-determination. In this case, we send a copy of our evaluation (or an outside evaluation if you provide one to us), to your insurance company. Your insurance will then let us know if therapy will be covered under your plan. The insurance company always includes a disclaimer on the pre-determination response saying that the pre-determination is not a guarantee of payment. However, once we have a pre-determination stating that the service is covered, it does provide a basis for an appeal if treatment coverage is ultimately denied by your insurance company.
Many plans require that your physician write a referral or a prescription for our services. We will let you know if we are told this is the case with your specific plan.
Test Therapy Session
Sometimes insurance is vague on what will be covered for speech therapy, so we offer to do one test session, billed to insurance, to see how they process the claim. If it pays, we can generally assume therapy is covered under your plan and subsequent sessions will be billed directly to your insurance. If your insurance does not pay for the test session, then we can assume your plan does not cover speech therapy for the condition presented. We can schedule therapy sessions at our discounted private pay rate.
Any medical provider who is “in-network” has agreed to accept a specific amount for the services he/she provides to you. This amount is different from insurance plan to insurance plan. If the provider charges $100 for a service, but the allowed amount is $75, then the total amount your provider will receive from you and your insurance company will be $75.
This is the amount of money your insurance company requires you to spend out of pocket towards your medical expenses before your insurance company will cover services. Not all plans have a deductible. Some policies have small deductibles of $250 per person, others have huge deductibles, yet others have no deductibles. We recently came across a plant that had a $10,000 deductible. The insurance company informs the provider how much of the deductible is left at the time the inquiry is made, and what the allowed amount for the service is. If you have a deductible that must be met before your insurance will cover speech therapy, then we will send you a bill once your insurance company informs us how much of your deductible is left and how much is your responsibility. We will expect you to pay the full “allowed amount” for each therapy session, as the insurance will not pay anything until you have met your deductible. Once you have met your deductible, the insurance company will begin to pay for our services.
Co-insurance – This is what your insurance company determines is your “share” of your medical expense for each service. If you have a 20% co-insurance, then if the “allowed amount” is $100, your insurance will pay the provider $80 and you have to pay the provider $20. You may or may not have co-insurance.
This is what your plan requires that you pay to the provider for each visit. Co-pays vary among different plans. We have seen some as low as $5, and others as high as $75. Some plans have no co-pay. If you have a co-pay, we are required by your insurance company to collect the co-pay from you at the time of each visit.
If you receive a denial from a test session, you can use the denial to appeal the decision of the insurance company. To appeal you will need a copy of your specific plan’s Medical Policy as it relates to speech therapy. We are happy to explain the policy to you if you provide it to us. You can get a copy of the plan documents from your HR dept. Be sure you request the Medical Policy, not just the Plan Summary. More on appealing your insurance company decision below.
Number of Sessions Allowed Per Calendar Year (PCY)
Many plans will cover a limited number of therapy sessions each year. If you have such a plan, once you have had your maximum number of sessions for the year, all remaining sessions will be your financial responsibility.
Using Diagnostic Codes
Our patients often tell us their insurance representative told them we used the “wrong code” and that is why therapy is not covered. This information is misleading! We are obligated to assign the appropriate diagnostic codes based on the medical information we receive and identify. We cannot call one condition something else in order to have your insurance pay for it. This would be insurance fraud. What the insurance representative should have told you is that the treatment for the condition identified by the evaluation is not covered by your plan based on the diagnosis. This means the plan’s therapy coverage is DIAGNOSIS DRIVEN. If you have seen a medical specialist and that specialist has made a medical diagnosis, make sure you give us that information. If the diagnosis is related to the speech and/or language disorder, we can use it and hope that will make a difference and have the therapy covered by your insurance.