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Planning for
Medical Needs
Specialized medical treatment is usually
needed for special needs children, sometimes beginning in a neo-natal intensive
care unit. Other times the need for such treatments arises much later, as you
or your pediatrician begin to notice developments that give rise to
questions.
You need to take precautions to ensure that
you make the most of your medical insurance coverage. Otherwise, you could be
left holding the bill — or a large part of it.
Obtaining medical insurance authorization for
specialized services and products, such as therapy or medical equipment, can be
complicated. The following are tips to better manage your medical insurance and
get much needed benefits paid:
- Read your policy! If you
have any questions about coverage, call your insurer and ask them to clarify
exactly what is covered, under what conditions and at what rate. For example,
traditional therapy services often do not take into account the specific needs
of infants and children requiring therapeutic intervention. There also may be
limits on therapy services.
- Create a one-page summary of your
policy provisions as well as one for limitations and exclusions. This
summary can be given to the treating physician or therapist, who will either be
writing a report or speaking to an insurance company representative on your
child's behalf.
- Check the list of participating
providers if you are part of a preferred provider plan or health maintenance
organization (HMO). You may be limited to using only providers within
the network. Make sure there are professionals qualified to serve children with
special needs. You may have the option of using out-of-network providers, but
be required to pay more out of pocket. The out-of-network option may be useful
if your child requires non-participating medical specialists such as pediatric
therapists or neurosurgeons.
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- Speak with the same case manager or
claims supervisor, if possible. When you call you insurance company,
ask for the name and phone number of the representative and try to speak with
that person every time. They will become familiar with the needs of your child,
and you will not have to repeat your child's story.
- Request a case manager be assigned
to you if your child has ongoing medical or therapy services. Working
with the same people can provide continuity of services.
- Include a photograph of your child
when you submit a claim or begin your relationship with a case manager.
Photos can personalize a case file, which might earn "special treatment" when
trying to resolve problems that might arise.
- Obtain prior authorization for
therapy, prescriptions or equipment from your insurer. Call your case
manager and ask if there is any procedure regarding prior authorization. Your
insurer may require a letter of medical necessity or the written prescription
from your primary care physician.
- Stay on top of your child's
case. Document everything, from phone calls to faxes, and include
dates. Send all correspondence by certified mail so you have a return receipt
for documents you send. Call the insurer if you don't get a timely
acknowledgement of your correspondence. Keep copies of everything.
- Obtain a claim denial in
writing. It should include the specific reason for denial. Insurance
companies are legally obligated to provide this. Question denials, and if you
believe the claim is valid, appeal the denial and resubmit the claim.
Making the most of your medical insurance can
be time consuming and sometimes exasperating. However, being the parent of a
special needs child also means being their advocate. By being organized and
proactive, you can give your child the best possible quality of life.
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