Alisa,

 

I would love the world Alisa. I agree with the global perspective you are sharing.  The amount of time required for me to accomplish it was a longer time frame however the outcome was well worth it.  I think you have touched precisely on the problem—we live in a society expecting us to accomplish more with less.  Many causes, such as this one, are dropped since we are not given the time to advocate for the clients we serve.  The unfortunate piece is the organizations, such as Disability Law, are fairly overwhelmed with several insurance and service related issues that these organizations have difficulty prioritizing them. 

 

I don’t believe the average SLP may have the support, education, and tools to successfully advocate for their clients needing an appeal.  My client died without receiving a device funded since the process was so long.  There are many who are benefiting from the insurance outcome of this unfortunate loss. 

 

Change will happen in small steps.  In the mean time, those of us advocating will be gnawing on our desks in the interim time frame as try to muddle through this insurance game.

 

 

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).

 

 

 

 

Ann Hoffmann| ALS Association MN Chapter, Coordinator for the Hrbek-Sing Communication and Assistive Device Program | PH: 763-520-0445 | 

Fax:  763-520-0355|Courage Center | 3915 Golden Valley Road | MPLS, Minnesota 55422
xxxxxx@xxxxxxxxxxxxxxxxx  | CourageCenter.org
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From: xxxxxx@xxxxxxxxxxxxxxxxxxxx [mailto:xxxxxx@xxxxxxxxxxxxxxxxxxxx] On Behalf Of Antoinette Verdone
Sent: Wednesday, May 13, 2009 8:53 AM
To: xxxxxx@xxxxxxxxxxxxxxxxxxxx
Subject: RE: [Assistive Technology] another AAC funding question

 

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?

 

Antoinette Verdone, MSBME, ATP

Assistive Technology Specialist

The ALS Association, Greater New York Chapter

NEW ADDRESS:

42 Broadway, Suite 1724

New York, NY 10004

 

Phone: 212-720-3054

Fax: 212-619-7409

Email: xxxxxx@xxxxxxxxxx

www.als-ny.org

 

"One cannot consent to creep when one has the impulse to soar"  -- Helen Keller

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From: xxxxxx@xxxxxxxxxxxxxxxxxxxx [mailto:xxxxxx@xxxxxxxxxxxxxxxxxxxx] On Behalf Of Alisa Brownlee
Sent: Wednesday, May 13, 2009 9:45 AM
To: AT National Listserv
Subject: [Assistive Technology] another AAC funding question

 

Hi all,

 

Since we have started a dialog on funding, I wanted to ask for feedback on another problematic problem.

 

We have had several incidents on a insurance company--primarily Blue Cross, giving our SLP's a difficult time on funding specific devices.  For example, a SLP may write a report for a My Tobii system and the Blues will call us and say  for example, "ATI is not part of our network, but "X" company is and I have already checked with the family and they say it is okay to change out the device for one that is covered in our network".  This has happened at least three times to us and now yesterday, I heard from an SLP in New York that Aetna has denied coverage for an ERICA System and will only fund one in their network--another vendor of an eye gaze product.   SLP is justifiably angry since this woman has been using an ERICA for the last four years!  (it was originally covered under a different insurance, is now broken, and she needs a new one under her new insurance plan)

 

Is this happening to others?  I want to try to keep track of this issue so I appreciate any feedback.  Insurance companies are bypassing therapists and doctors and making decisions based on in-network vendors, not what is appropriate for our PALS.

 

Thanks,

Alisa

 

Alisa Brownlee, ATP
Clinical Manager, Assistive Technology Services
ALS (Lou Gehrig's Disease) Association, Greater Philadelphia Chapter

 

Assistive Technology Consultant, ALS Association, National Office

Direct Phone Number: 215-631-1877

 

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