Hell hath no fury like an angry momma bear with a law degree. Let me explain. When Layla first started receiving speech therapy, coverage for her services was denied because her delay was developmental in nature, and therapy for developmental delays was excluded in the policy. I thought, “Well, that sucks, but let’s get her help now so she does not have a speech issue later.” So, when Eli began receiving speech therapy, we did not even try for coverage, having learned that developmental speech would not be covered when we tried years earlier. But, once Eli began needing more sessions, his diagnosis took shape and I learned more about apraxia, I got mad. My son has a neurological condition that will not get better with time. He is not a “late talker.” That screams medical not developmental! Why do I even have insurance?? And I wanted to scream.
I went to Eli’s therapist and asked for copies of bills for ALL of 2015 to submit to Cigna (that’s right, I named you–pay up!). I’ll spare you the dreadfully boring back and forth, but over several months I received repeated requests from Cigna for different diagnosis codes, NPI numbers, tax ID numbers, and more. Suffice it to say, I am now an expert in billing for speech services. Beyond that, I got the feeling that I was being buried in paperwork. Aw, HELL no. Anyway, after numerous hours on the phone and a lot of back and forth, Cigna finally deemed the claims complete and worthy of a decision…and they were promptly denied for failure to seek pre-certification. In other words, we were supposed to ask Cigna for coverage for the service before getting it. But guess what? We did, in February. And Cigna denied it!
Insurance companies bank on the fact that most people won’t respond to the supplemental requests for codes or more information–and even if they do, they will not go to the trouble of filing an appeal once a claim is denied. Therefore, the insurance company never has to pay out the majority of claims. That is unfortunate, because these extra steps, while time consuming and frustrating, can lead to reversals, and the insurance companies SHOULD be footing the bill for kids like Eli, and for others with medical conditions that require treatment. It just makes sense.
In filing my appeal, I took the extra steps and more. I worked in one of the busiest prosecutor’s offices in the country writing appeals and handling several hundred cases at a time. I also spent a year at a law firm doing, ironically, insurance and med mal defense. So, I am very familiar with how to put together a persuasive appellate brief and how to argue my case. I have set up a mini command center in my office where I keep copies of everything related to Eli’s treatment, including documenting phone calls, getting names of people I speak to, asking for supervisors when necessary, and so on. For the appeal, I wrote a letter detailing Eli’s diagnosis and history in speech, and explaining that in fact, we HAD sought pre-certification, but it was denied. I included exhibits. Eight exhibits. Over 100 pages. Personal letters from my pediatrician, Eli’s therapist, all of his IFSPs (fancy abbreviation for the periodic early intervention reviews), medical research about apraxia, correspondence with Cigna. Insane? Maybe. But momma is not messing around.
I may need a new folder.
I sent the appeal in this week by certified mail with a return receipt. So, before Cigna could even open the envelope, they had to send back a postcard to me showing that they received it. That way, they can never deny receiving it. I received the green postcard this week. Here’s hoping I get reimbursed for the several thousand dollars spent in 2015. If so, drinks on me!
In the meantime, I also requested billing statements for the first quarter of 2016. I will submit those and undoubtedly be denied. Then, I will send in the same appeal packet, unless something changes with our coverage going forward and retroactively when they decide the first appeal. I doubt it, but I will keep fighting, and I imagine the day when my relentlessness will wear them down.
At the same time all of this was happening, I asked Eli’s therapist’s office to start billing Cigna directly starting second quarter 2016. They sent a letter from his therapist along with the pre-certification request. Guess what I got yesterday in the mail? Yep, a denial. Why, you ask? Because the services requested were for a “developmental delay.” The denials allow for an appeal as well, so I promptly photocopied my eight exhibits, rewrote my appeal letter to explain once again that apraxia is medical, and not developmental, and will head to the post office by the end of the week. Wash, rinse, repeat.
Are you reading, Cigna? The only people you are hurting by denying speech is the children who so desperately want to speak. They know what they want to say, but because the link from their brain to the speech organs is off, they can’t. Can you imagine how frustrating it must be to live in a world where you know what you want to say, but no one can hear it or understand you? I hear you loud and clear, Cigna. You seem to have no problem with communication. But I’m coming and fighting for Eli.