If SMA was the only thing we deal with then it would be much easier but alas, we need equipment, therapy, and nursing care. The prices set for these services makes it nearly impossible for someone to pay out-of-pocket. We, as bad as it is, we are stuck with it and have to find a way to get the most out of insurance. We've learned a few tricks and tips that should help you out along your way.
Now, there are two types of insurance: Private and Public (aka federal, Social). Private like what you get from your employer, can be expensive itself but it's still only a fraction of equipment and services prices if you paid out-of-pocket. Public or social insurance such as medicaid, is free but because of that, it can be a little harder to get individual components covered (this highly depends on the state you live in though). The first thing you want to do when establishing insurance is deciding how much coverage you need.
Some families actually purchase multiple private insurance coverages (husband and wife both work). This offers the best overall coverage because when one company rejects a claim, the other usually picks it up. For instance, in-home physical therapy is not covered by my specific Blue Cross Blue Shield plan, but my wife's insurance coverage CIGNA, covers this. We have multiple examples of working the differences between the two companies and their coverage.
With dual coverage, the Primary insurance for your child is determined by the whomever's birthday comes first in the year.
The second biggest thing you need to establish is a Case Manager. A Case Manager works with the specific individual to help justify the need and lobby on their behalf. The can help overturn a rejected claim and navagate the required steps. The case manager should be one person which is the benefit of individual case management. If you are offered a case manager and it's multiple people, then it's not a true case manager. Find one person at your insurance company to work with and go through them for everything.
Tips to establish a case manager relationship.
- Build a personal website with pictures of your child that he/she can see. They need to know what you are dealing with.
- Get the direct email address of your case manager and send thank-you messages with images (preferably using the equipment that they helped you approve).
- Call this person exclusively and if needed leave a message. It may take a day or two longer to get your answer, but it helps strengthening the relationship.
- Don't vent - nobody wants to hear someone bitching. Instead play to their empathy and talk about how this affects you and your child.
This case manager is a huge asset and can help to instruct how to appeal denied claims or the wording to include for a greater chance it will be approved. REmember this tip when submitting or having someone submit on your behalf to your insurance. The insurance companies job is to deny your claim. That's not being cynical it's the truth - an insurance company is only profitable if they take in much more then they give out. Knowing that, your job is to make sure you submit as much information as possible so there is no way they can deny it.
A few ways to increase your chances of getting an approval:
- Have your doctor or PT/OT write up a letter of necessity for the particular equipment or service.
- If insurance asks to demonstrate the need or ability for equipment (often for powerchairs) included a DVD video of your child doing the thing in question.
- Contact the vendor to ask for advice - they want to sell the product so they may have tips from previous experiences.
- If you have dual insurance, go ahead and let the first company deny it so you can submit it to your secondary insurance.
For more information regarding equipment you can also read the article