Because there are many as-yet unproven treatments, and so many treatments seem to work for some children but not others, parents may wish to try every available option. However, they may be dissuaded from doing this by the financial burden all of these treatments would impose. However, many of these services CAN be covered by health insurance. In order to understand the specifics of your insurance plan, you should call your insurance provider help-line or human resource line to become familiar with your insurance coverage and options. The following is a list of services that can be covered by health insurance (Note: there is no guarantee of coverage):
Sometimes you may want to take your child to a doctor whose services are not directly covered by your insurance plan. In this case, you’d be forced to pay an out of pocket expense to the provider, but you would also receive a receipt or invoice describing the service and payment that has been made. In this case, you may still be able to have these expenses covered, but you will need to fill out reimbursement forms (get these from your insurance provider) and send these in along with the invoice that you received for the services. Note: It is extremely important that the invoice or documentation mentions that the parent has already paid for the service and that there is a zero balance on the receipt. You should then send a cover letter explaining that you have already paid for the services mentioned, and that they are requesting a reimbursement. Be sure to send along any type of payment documentations or notifications that relate to the specific doctor’s visit as well.
Biomedical treatment, or treating a child through the use of specific nutrients can become extremely expensive for parents to deal with. Since the science behind biomedical treatment and how it correlates with the conditions of autism is still being researched, there are no approved or insurance-covered treatments available for children. Nevertheless, there are ways in which parents can go about saving money on these treatments:
1.) Do your homework and research treatments to determine whether or not there is a good chance that a specific treatment will benefit their child. There are many books, websites (including this one), and medical journals, which describe treatments in detail, and can provide a lot of information. Take this knowledge that you have gained about each of the treatments and discuss it with your child’s specialist.
2.) Keep copies of EVERYTHING (lab tests, doctors appointments, therapist, school IEPs, etc.) Most importantly, list your child’s responses to different treatments, and make a journal of how each treatment affected your child.
3.) Use insurance for all doctors and labs. Not all doctors accept insurance, but it is important for parents to request that the doctor uses insurance-covered labs whenever possible. Doctors must also be sure to use good coding, so that treatment can be reimbursed. Parents should make sure that the doctor never bills anything under “autism,” because there are no approved “treatments” for autism. Instead, they should be listed as specific medical conditions, such as constipation or allergies that need to be treated, and the doctor must code these conditions by their specific names in order to ensure reimbursement.
4.) Remember to bill your Medicaid or waiver programs to cover what insurance does not cover. Medicaid usually does not cover autism specialists, tests, or treatments, but they usually cover co-payments for visits and prescriptions and lab tests performed at hospitals. Try to bill your primary insurance first, and if that does not work, go through Medicaid as a last resort.
5.) Find out if your insurance company will cover compounded vitamins and supplements for your child. If not, a way to avoid spending so much money on these is to experiment with sample sizes or trial versions of the medicine first, before purchasing in large quantity.
6.) Never start more than one kind of treatment of any kind within a 2-3 week period. If too many treatments are used at once, and a child has a bad reaction, you won’t be able to tell which one of the treatments was the one that negatively affected your child. If the child has a good reaction, you won’t know which treatment is working.
7.) If you must resort to consulting a specialist or using a specialty lab that isn’t on your insurance plan, ask your insurance-covered physician to rewrite the prescriptions acquired during these visits so that your insurance will cover the expenses.
8.) Be sure not to waste money on doctors and treatments that do not seem to be working. Just because a doctor says that a great number of children have benefited from a specific treatment, this doesn’t mean that you should continue the treatment if it is not showing any benefit for your child.
Though there are many ways to have treatments covered, parents are still frequently denied coverage. The important thing is to be as knowledgeable as possible about the insurance company’s requirements for coverage. By gaining a good grasp of the information provided in this section, and being familiar with your insurance company’s specific policies and guidelines, you will be able to understand the rights you have, and you will be able to recognize when it would be beneficial to put up a fight when you are denied those rights. If you find yourself in a situation where you feel an appeal or fight is warranted, the following explains a basic procedure:
1.) Call the insurance company and confirm that there is a denial.
- Ask for reasoning
- Ask to verify diagnosis
- Ask to verify the treatment
2.) Next, an appeal should be filed
- Become familiar with the insurance company’s guidelines and process for filing an appeal, and follow them step-by-step
- Be sure to use the proper forms for filing an appeal, and be sure not to miss any deadlines
- Request a formal review of your appeal (be sure to go to somebody in the department dealing with autism)
- The following breaks down what to include in the appeal letter:
- Parent contact information
- Insurance information
- Dates and description of the given service
- Doctor referrals
- Any references to benefit packages that support coverage
of the service at hand
- Any supporting information in general that gives support of coverage
- If treatment is covered by Medicare, mention it
- Send the letter by certified mail, and send a copy to your
physician, employer, and state’s Department of Insurance
- Always send photocopies and never the original copies
3.) Lastly, make an appeal with the state Department of Insurance
- Get in touch with the Department of Insurance in
your state and ask them for a copy of the state’s standards for
health insurance.
- Ask the Department of Insurance about Employee Retirement
Income Security Act (ERISA). This is a streamlined employee
benefits package, and it could be useful for parents.
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