60 visits…..are you kidding me?

by Karla Barnett on January 22, 2012

For the life of me, I will never understand how or why insurance companies limit the amount of therapy visits a patient can receive. What is the number based on….other than the old might dollar!!! Therapy services allocated per year, at least in my case is 60 visits. The number includes occupational, speech and physical. If my son required all three, which he did at one time, he is only covered 20 weeks out of the year. What am I suppose to do the balance of year? What are my options?

• Cover the cost out of pocket at $1,000/week
• Determine which therapies are most important and attempt to perform the others on my own

Not only does the insurance company dictate the # of visits but they also determine if the treatment plan is required. Keep in mind, they have never seen my son, nor do they know his history but I have to fight tooth and nail with a customer service representative, who is not qualified to make the determination. As if I don’t have enough on my plate, I have waste my time pleading my case for his treatment. Last year, the insurance company tried to deny all of his therapies indicating they were not medically necessary. Really????? He has very little speech and struggles with fine/gross motor skills and has sensory issues. I consider those reasons medically necessary. Oh and by the way, I have a script from my doctor deeming the treatment medically necessary. I believe that trumps your decision. What a nightmare!

I challenge anyone from the insurance company to stand in my shoes for a day and then provide me with their decision. I’m sure if a few of the executives had special needs kids, requiring therapies, the criteria would be a little different. Don’t get me wrong, I totally understand the business end of things but not when comes to interfering with my kiddos progression.
I do realize that I am one person but this is a hot topic for me and MANY others and I plan to add it to one of the items I add to my list to take on!!!!! As always, I’m looking for your feedback and solutions?

{ 14 comments… read them below or add one }

Lauren January 22, 2012 at 8:04 pm

When my son was in school, he needed all those therapies and more, several times a week each. With few exceptions, the school district provided all of it.

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Karla Barnett January 22, 2012 at 8:16 pm

Lauren, the schools do offer therapy but it’s minimal. 15 for speech and OT.

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Kim January 22, 2012 at 8:08 pm

We only get 30 visits a year. Its very frustrating. I try to learn everything I can while I am at therapy so I continue to implement what the therapist is doing once we run out.

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Karla Barnett January 22, 2012 at 8:17 pm

Kim,

It is extremely frustrating and sad.

Karla

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Tanya January 22, 2012 at 8:40 pm

How about ABA? That was a whopping $10K out of our pocket for 15 hours a week for only 3 months so I could learn how to do it myself. Not. Fair.

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Karla Barnett January 22, 2012 at 9:04 pm

Tanya,

It’s really unfair! Don’t get me started on the supplements that are not covered by insurance. They really need to spend one day in our shoes!!!!

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Anna August 1, 2015 at 6:08 am

Amazing that This Conservation group who I guarantee will not spuoprt me when I run for Council Some Day in Sonoma, Does Not have a single person from our Town on their Board- Most are from Sebastopol where I grew up, Guess what folks Compared to the Sebastopol that I knew, it is has lost it’s place, Take care of your own Backyard before you wander over to the Soul of Sonoma County-The City of Sonoma and those of us who serve the community everyday.

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Sara August 2, 2015 at 11:55 am

Oh Cindy, your tree is just dripping with btfueiaul ornaments! I love the flocking, too — it’s so right for your home. Love those vintage ornaments, especially the silver ones in the apothecary jar — btfueiaul! And a pink Santa for your bedroom — perfect!Thanks for sharing!xoxo,Mary

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Karen February 15, 2012 at 6:35 pm

Music therapy costs half of OT/PT/speech and will incorporate all of your OT, speech and social goals. Also, you can get parent training written into your IEP and learn how to do therapy at home.

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Karla Barnett February 16, 2012 at 9:09 am

Karen,

Where did you take your son for music therapy? I was discussing music therapy with his teacher and I know he would benefit from it.

Karla

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B. March 7, 2012 at 1:06 am

Hi Karla -

Just wanted to provide some perspective here since I spent much of my career in health insurance. The number of ot/pt/st visits is determined by the plan your [husbands] employer chooses when they select the health coverage they wish to offer their employees. While 60 visits is higher than most, some people have unlimited or 60 visits for each therapy type. Often the people making the decisions what riders / coverages go in your employee benefits plan are basing those decisions on their own experiences, so if therapy is a need for them, you get it and plenty of it. If not, you don’t. Same for things like wigs for chemo patients or therapeutic shoes and even what ur out of pocket costs will be for each service. Appeal to your [husbands] employer, let them know there is a need & they may be able to build it into the upcoming years coverage.

Have a great one.

B

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Karla Barnett March 7, 2012 at 8:16 am

Thanks Amber!!!! We are in the process of appealing and praying for additional visits.

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Talis August 1, 2015 at 6:58 am

-2-Harrywr2That presupposes that there is ninhotg of value in the rural areas. We could all live in one small state on the East Coast, but it would be one heck of a commute to work. Even D.C. couldn’t employ all of us.

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Hunti August 2, 2015 at 5:47 am

Oh, I just love Karla and her work! We have been online fdiners for a while and I am always comforted, excited and inspired by her insights and observations .and always so thrilled when she does a post on her blog, I always know there will be a nugget of goodness in each post! She was the perfect person for you to email with your question about prints, she is always so open to helping others.

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