Information on Insurance Reimbursement
What is a "covered service"?
Many insurance companies include "speech therapy" under their covered services. Unfortunately, access to that coverage is often quite restricted. Most companies include the clause "when medically necessary to restore speech functioning following illnesss or injury." This clause negatively impacts most of our patients.
These clauses are usually interpreted by the insurance companies to be speech/language/voice loss following head injury, stroke, vocal surgery or radiation, etc. They are almost always specifically disinclude "developmental" speech-language disorders or "habilitative" treatment. "Habilitative" treatment means that the speech/language capability was never complete, so the treatment is not "rehabilitative or restorative". This of course, would then disinclude all "learning disabilities", developmental (i.e. from childhood) stuttering, and even some voice disorders of uncertain etiology.
Even if your insurance company has given you the information over the phone that you or your child will be covered for speech therapy, they may reject your claim once you have submitted it due to the specific diagnosis. Unfortunately, this is common practice.
Requesting Pre-authorization of an Evaluation
Still, submitting the claim to the insurance company is worthwhile. It is best, however, to ask for pre-authorization of any services, but be aware that it can take many weeks before your insurance company will respond to such a request.
If you wish to have the evaluation covered, you should get a statement from your physician (or your child's pediatrician) stating that he/she is "referring" you for "an evaluation of [the speech/language/voice disorder]". You should send this to your insurance company together with your letter requesting "pre-authorization" of the evaluation at this clinic. If the insurance company agrees to pay for all or part of the evaluation, they will generally send us a fax to confirm that. Some companies will send the authorization to the patient.
Requesting Pre-authorization of Treatment
When we have completed the evaluation, we will send you a full report, and, if we are recommending therapy, a treatment plan. You will also receive our statement for the evaluation fee, containing the diagnosis code and the procedure codes. You should then have your physician sign the treatment plan, and submit the following to your insurance company:
- Your statement;
- The treatment plan (signed by your physician);
- A copy of the physician's referral; and
- Where applicable, your insurance company's medical claims form. Be sure that you have entered all the requested information and that you have asked that the reimbursement be sent to you, not the provider. (We do not accept direct payment from insurance companies.)
It is best if we fill out the "Provider Section" of this form.
Send the above to your insurance company with a cover letter requesting a "predetermination of benefits". The company is required by law to respond within 14 days and tell you whether or not they plan to cover the services described under the Treatment Plan.
If You Receive a Rejection Notice
If the company rejects your claim, they must give you specific reasons. If speech therapy is specifically excluded from your plan, then this is a final rejection. As we initially pointed out, most commonly, speech therapy is included but only for the results of "medical conditions". Sometimes, based on the nature of the rejection, we can prepare a letter to the medical claims examiner, explain the nature of the disorder, and the rejection will be overturned. Please be aware that this is becoming less and less likely. In today's health care climate, ancillary services are the first to be cut back.
How Much Will be Reimbursed?
A question often asked by patients is: "How much of the cost of therapy will my insurance cover?" Some companies cover 50%, others will reimburse up to 85% of whatever fee the insurance company has deemed "reasonable and appropriate." This is hardly ever the actual cost of the treatment, nor does it in general reflect the average cost of treatment in your geographical region. It may, in fact, be less than half the fee, so that the 80% is actually only 20% of the actual fee.
It is also important to remember that there may be special considerations on your policy, for example: the first visit to a provider may be excluded from payment, or a policy may reimburse only for a specific number of treatment sessions. (Usually in this case, it is required that a progress report be submitted and further therapy be approved.) Some policies have a yearly limit on services.
When to Submit Statements
Once the company has agreed to reimburse you for the cost of your therapy, you should send in your receipts on a regular basis (most companies do not require that you fill out a new medical claim form each time you submit a statement for the same provider), rather than letting statements accumulate and sending them all in at one time.
How Can We Help?
We will provide appropriate documentation in the form of itemized bills with accurate diagnosis and procedural codes which will be recognized by your insurance company's computer system. We provide a complete, accurate evaluation report and a clear treatment plan which includes recommended frequency and duration of treatment (required by insurance companies). If you or your child are in treatment, we will provide reports documenting progress at the intervals required by your health insurance carrier.
However, we can only help you receive reimbursement if you follow your company's procedures carefully.
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