Part of our strategy for having successful IEP Meeting results was to get private psychological testing (10.5 hours worth done by a psychologist). The testing results and having the psychologist participate in the IEP meeting was pivotal to getting our son the services he needed.
The testing cost $2,500, which we paid out of pocket. Now we are doing the insurance battle. The charges were denied because Aetna PPO said the testing was “educational” not medical. Our son is diagnosed as ADD (by a psychologist and a psychiatrist), and dyslexic (by a psychologist and the school). We have received reimbursement for OT Therapy services and vision therapy services. We are going to go through the final appeal process which requires sending all of our son’s medical records to Aetna (PPO) and they will have an independent expert review the records.
WHAT STRATEGIES DO YOU RECOMMEND FOR GETTING THIS REIMBURSED? Are there any specific diagnoses or wording I should have the professionsals use in a cover letter to go along with the records? I was thinking of having the following folks send medical records and a coverletter (they are all willing to work with me to help me get reimbursement): the pediatrician, the private psychologist, OT Therapist, vision therapy physician, psychaitrist. Thanks in advance for your help!
Re: Getting Reimbursed By Aetna PPO For Psychological Testin
No words of wisdom here, just sympathy. I’ve been fighting Aetna for 4 years to get my son’s OT and speech covered. (yes to OT, yes to some of the speech. Now they tell me speech isn’t covered - hello?) The key to getting the speech covered was getting therapists notes.
We also just spent $2500 on private testing, and are debating whether to send it in. We also just spent $1000 on a psychiatrist, and I expect my son will be having therapy for some time. Good luck.
Re: Getting Reimbursed By Aetna PPO For Psychological Testin
I feel your pain and frustration!
If you are half-way organized and tenacious, go for filing the claim all the way to the final appeal, and if that does not work identify who your Work’s HR contact is who has the power to over-rule the insurance rejection. Ultimately the insurance company works for your employer. Also, I was given the advice this morning to get the name, title and telephone number of an insurance supervisor to send any denied claims to. Make it personal and hold them accountable.
Try this, I’m going to next week: ask the professionals you are working with to list out all the treatment and diagnoses codes they feel comfortable assigning to your son. Call Aetna and go down the list and have them anser “yes” or “no” will they cover the codes, one by one.
I’ve been down the road of Psychiatrist eval. I had to have it pre-certified since it’s under behavioral health. Even if you have had the appointment you can call Aetna and have a series of visits approved. Of course in network psychs give you better coverage.
I have Aetna PPO, but I’m finding it’s pretty much the same coverage 70% for OT Therapy, vison therapy, etc.
Re: Getting Reimbursed By Aetna PPO For Psychological Testin
Consider yourself lucky that you can get even part of OT and vision therapy covered. No luck here with Prudential. It’s all considered development which is not covered. Go figure, LD’s are neurological disorders yet remediating the problem is not covered, yet we can get reimbursed for plastic surgery.
We recently found out that since our company is privately insured, which is usually the case with most large companies, they are ultimately responsible for any denied claims. Definitely talk to your head hancho.
School district reimbursement
If the school district used the assessment to give your child services, why are they not reimbursing you for the assessment?
Re: School district reimbursement
The schoold did their own testing , but it was over a year ago. They only retest every three years, and by that time a child is completely lost. That’s why I did testing on my own, plus my child’s IEP goals were not measurable or specific to what he needed.
The psychologist coded the 10.5 hours of testing with a dual diagnosis: both dyslexia-related (education) and ADHD. I did not know that until yesterday. The insurance company ignored the second diagnosis. So I’m hoping for 50% reimbursement. The psychologist, psychiatrist and the pediatyrician will write a letter of necessity based on ADHD, I’ll resubmit which means the insurance company will pay an outside person to make a decision. If that does not work I will go to the appropriate HR person at my company.
What’s interesting is the psychiatrist’s bill came and insurance only paid for 50% of it. I’ll investigate that as well.
still don't understand
Yes, school’s only test every 3 years unless you request otherwise. We are in a similar situation. Our son was tested last year, their testing does not in anyway indicate his difficulties, in fact they say he scores at and above age level. The testing was not enough to indicate the huge problems he is having. We requested independent testing, they denied it (independent testing that is more thorough and less biased). We will be getting the testing done on our own and submitting it to the IEP. They have to accept our reports. Once they do, it is my understanding that they have “bought” the report and must reimburse you for costs, even if you did not previously request them to pay for it. (we actually have filed for due process on this). The law seems pretty clear, but I am not certain. We are in California, maybe it is different where you live, but seems it would be worth checking into. If those tests indicate difficulties and they are providing any services based on the information you submitted, any goals, anything it seems to me it is now their report.
Re: still don't understand
It is my understanding that the school has to consider outside testing you submit; however, I did not think they were obligated to pay for it. THe stance my IEP team takes is “If the team did not make a decision to do it, the parent’s are on there own”. They get defensive if you tell them you made an appointment with a specialist (3 months out) and you are asking the team to consider the need for testing and paying for it.
We’ve won the war becuase our son will be going to an LD school during the summer and in the fall. The LD school does a series of tests annually.
If you can accomplish getting your son’s needs without due process that would be optimal. Don’t win the battle (reimbursement for testing) and lose the war (wasted time in due process when the focus should be on getting your child the help he needs). We were pleasantly surprised that we acheived our goal. We thought it would take another year of trial and error at the school.
I prepared for the IEP by getting great advice from a paralegal. Every other day prior to the IEP I e-mailed correspondence to everyone on the team. I presented our “parental vision” for our son, went point by poin in writing about all the concerns we had with the existing IEP and IEP attainment, and I rewrote all of his reading goals myself (it was 10 pages, specific and measurable). I had a lot of behind the scenes help rewriting the goals.
It was clear that we were serious and that I’m sure they sensed due process was in the future based on the details I outlined and documented in writing.
Only use the medical diagnosis of ADHD, it is a medical, not educational condition, and if you used providers in the Aetna network and got the correct prior approvals, you should get covered. They will not pay for achievement testing or IQ testing unrelated to the diagnosis of ADHD. Do you have a flexible spending account(where you shelter pretax dollars) at work(for unreimbursed medical, dental, etc. expenses)? Maybe you can submit your other bills through that.