Cary Speech Programs are Affordable

Our programs are affordable. We will file insurance electronically at the end of each month. We also take most insurance plans.

We are in-network with these companies.

          We do not participate with Medicare or Medicaid

  • Blue Cross Blue Shield of NC and all other states
  • State of NC Health Plan
  • Blue Cross Blue Shield Federal
  • Tricare – Health Net Federal
  • Wellpath Select
  • Aetna
  • Private Healthcare Systems
  • Cigna
  • United Healthcare
  • Integrated Health Plan
  • Government Employee Hospital Assoc. (GEHA)
  • Great West Healthcare

Dealing with Your Insurance Company for Speech Therapy

Estimates show that at least 30% of patients seeking pediatric speech, language and hearing services are denied coverage for recommended treatment by their insurance companies. Although many insurance plans state that medically necessary speech-language pathology services are a covered benefit, in actuality these claims are denied. What insurance companies cover is often not immediately evident because it is not explicitly stated in the plan booklets that employees are given. Frequently, coverage of speech-language services includes only acquired disorders such as inability to speak as a result of a stroke, head injury or an illness such as viral meningitis. Developmental or congenital disorders that affect children from birth are increasingly denied. Families and employers often mistakenly believe that services for children are a covered benefit. Not until treatment of the child has begun and claims have been filed and denied, do the parents realize that they have a problem.

Authorization Process

Even when an insurance plan does provide coverage for children, the authorization process that providers and clients must comply with in order to obtain reimbursement can be very slow and inefficient. Sometimes documentation must be provided before treatment begins and then monthly progress reports must be submitted in order to continue treatment. Some insurance companies that do cover treatment have a cap on the number of sessions allowed in a certain time period, such as 20 sessions in 60 days. This is usually an arbitrary number and it is rare for companies to make exceptions.

Do your homework

So what can you as a parent do to ensure that your child gets the needed speech-language services that have been recommended and also get your insurance company to help defray the cost? First, you need to do your homework. When you signed on with your insurance company, you were given a benefit manual that tells what your plan covers. Read it carefully and see if it mentions speech-language therapy. Does it state whether it will cover services for children? Does it use vague language, like saying that it will only cover if the services are “medically necessary” or if the speech disorder is the result of an illness or injury”?

Next, call your insurance company and explain your child’s problem. Ask if your plan will cover treatment for this complaint. Make sure that you document on paper everything that the claims representative tells you. Get his or her name and make sure you write down the date and time that you had this exchange. Ask if you have a deductible to meet and also whether you have a co-payment and if so how much. Put this paper somewhere safe. You will need it if your claim is denied.

Are referrals required?

You will also need to know whether your pediatrician has to make the referral and if he/she needs to write a “letter of medical necessity” to the insurance company. Does the doctor also generate an authorization number that the speech-language provider will need to file the claim?

So now it looks like all your “ducks are in a row” and we can begin treatment of your child. You feel sure that the claim will be covered by your insurance company. Surprise!! Two months and ten therapy sessions later you receive an “Explanation of Benefits” from the insurance company that states that they are denying payment on the claim. What should you do now?

If your claim is denied

Well, don’t panic! You do have recourse. Somewhere on your EOB (Explanation of Benefits) will be a code that tells why the claim has been denied (sometimes this is on a separate sheet or on the back side of the form). Sometimes the insurance company just wants more documentation of the problem, either from the speech-language pathologist and/or from the physician. If it is unclear why they are denying the claim, call the company. If they are flat-out denying coverage then you are entitled to an appeal.

Now, how to appeal a denied claim. The company will usually tell you how many days you have to submit a written appeal; it is usually 60 days. Remember that documentation that you did when you spoke with the insurance representative on the phone before you started the treatment process? Now is the time to dig it out and use it. You will also want to talk to your child’s therapist and see if she can provide additional documentation about the disorder that your child has. A progress report is also helpful. Many insurance companies will pay a claim if there is any evidence that the speech-language problem is possibly the result of a physical problem, such as recurrent ear infections or a mild hearing loss caused by fluid behind the eardrum. Does the child have evidence of a mild neurological problem such as dysarthria or dyspraxia; does the child have a chromosomal problem like Down’s syndrome; is there evidence of autism or Pervasive Developmental Disorder? Does the child come from a family where there is a history of stuttering? Has the child been treated frequently for upper respiratory problems or asthma? Your physician can be a good resource, especially in providing documentation of any of the above problems. It might also be helpful to ask the physician to write a letter stating that speech language therapy is “medically necessary”.

Please note that insurance companies are not used to people appealing their denials. The majority of appeals for speech-language therapy (about 90% in our office) are reversed. So don’t take “no” for an answer!

Your insurance appeal

Okay, you mailed in your appeal (faxing is even better; then you will KNOW it got into the right hands). Now what? You will need to determine whether you want to stop the treatment of your child here while you are waiting for the verdict. Realize that you are responsible for payment of your claim, whether or not your insurance covers it. If you choose to continue with treatment, you may want to put the payments on a credit card and pay the bank the minimum balance each month. Be assured that you will get a prompt refund from Cary Speech Services when your insurance pays us.
We recommend that you call your insurance company and ask at what stage your appeal documents are and whether they have made a determination yet. It is always helpful to get names of people involved in the process so that you can speak to them directly without going through several transfers. Get direct extension or phone numbers to the key players. Call frequently (at least twice a week) so they will know this is very important to you.

What else should you do?

Is there anything else you can do while you are waiting? YES!! Talk to the human relations officer at your company. Let him or her know that your employer’s insurance carrier has denied a needed service for your child. Explain how the insurance coverage booklet was misleading. Register your dissatisfaction with their choice of insurance company. Let them know that you will expect better coverage in the future; that you want them to negotiate coverage for children with speech-language problems. You need to educate your employer about your needs. Some companies have a special plan to cover medically-related services for children when major medical is not enough.

If you lose the appeal, we suggest that you write a letter to the insurance commissioner of North Carolina and formally register a complaint about how you were misled by your insurance company’s promotional material and claims representatives. If enough families complain, the insurance company will be investigated. You can also educate your legislators about the limitation of pediatric insurance coverage for children with special needs. In addition, you can also submit articles and letters to the editors of the local newspapers.