The best solution is “go to the mattresses”.  Start a dialogue with the insurance company Director of Medicare and Medicaid to begin a discussion regarding what is medically necessary.  This is a dialogue I initiated with an insurance company this January regarding a specific case.   It also helps to get your local Disability Law Center involvedJ. For some reason, people are nervous and become attentive to your message when lawyers are involved. 

 

At the time, I believe one company was being authorized for payment otherwise the rest were considered “out of network”.  Once I was done with a 3 week dialogue regarding a specific case, I was able to offer contact  information for the funding coordinators of all the AAC companies to the insurance company and the funding coordinators a connection to establish “in network status”.  There are still a few kinks being worked out however now I have an insurance company who provided cost plan Medicare replacement policy processing paperwork when it was denying for the reason of being “out of the network”.  The great reward for funding coordinators is that they now have one person to contact for device submission questions.

 

 As a therapist, what I found most frustrating about the process was the lack of education individuals reviewing the submission knew about the federal guidelines for AAC, who was the specialist to recommend this technology, even an understanding of the evaluation process,  and how it is processed (not through the physician’s office—oh boy.). It allowed me to offer education about the Medicare and MA guidelines to clarify questions the reviewers have.  I also gained the perspective into the reviewers world.  They really don’t get much training and even their managers are not fully aware of the guidelines either. 

 

One way to begin the dialogue is to develop an understanding of how the insurance company decided to accept certain manufacturers as “in network providers or preferred providers”.   If the insurance company is representing Medicare or MA, Medicare and MA do not have a regulation allowing an insurance company to establish “in network providers”.  Medicare and MA have established contracts with AAC companies that accept their assignment.  Insurance companies representing Medicare and MA must follow the same guidelines and authorize payment for communication devices.   Through this dialogue I found out how different a Insurance cost plan  that is a Medicare Replacement plan is, how the funding departments are required process it differently, how to jointly work with an insurance representative, and how the insurance company can change their process to improve the processing of this paperwork.  As a result of this dialogue, this company is even covering the co-payment when it is the secondary insurance (which it denied payment for years!).

 

This was a small victory I wanted to share. 

 

It is not an entirely rosie world in MN.  We still have other insurance companies misbehaving (e.g. establishing “in-network providers”—BCBS).  It is slowly improving  as I learn to work within the insurance network to overturn the nonsensical ideology now a policy.   I lean on other organizations to fight the battles I do not have the time nor resources (e.g. Disability Law Center, MSHA (Minnesota Speech and Hearing Association,) American Speech-Language Hearing Association, ALS Association).    I have to believe there are enough good people in the world that this too shall pass.  It is a matter of motivating others to initiate the “change we believe in” (borrowed from President Barack Obama).

 

 

 

I don’t understand how the insurance companies are getting away with this.  It is one thing to have “in-network” vendors, but it is another thing to have in-network products!  Is this not violating some sort of insurance rules?  Can they say – you HAVE to get a Buick, and a Toyota is never appropriate?

 

 

 

 

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