Insurance and Payments

The Lowcountry Therapy will provide appropriate documentation in the form of itemized bills with accurate diagnosis and procedural codes that will be recognized by your insurance company’s computer system. We provide a complete, accurate evaluation report and a clear treatment plan that includes the recommended frequency and duration of treatment (required by insurance companies). If your child is in treatment, we will provide reports documenting progress at the intervals required by your health insurance carrier. However, we can only help you receive reimbursement if you follow your company’s procedures carefully.

Many insurance companies include “speech therapy” under their covered services. Unfortunately, access to that coverage is often quite restricted. Most companies include the clause “when medically necessary to restore speech functioning following illness or injury.” This clause negatively impacts most of our clients.

These clauses are usually interpreted by the insurance companies to be speech/language/voice loss following head injury, stroke, vocal surgery or radiation, etc. They almost always specifically exclude “developmental” speech/language disorders, or “habilitative” treatment. “Habilitative” treatment means that the speech/language capability was never complete, so the treatment is not “rehabilitative or restorative.” This typically includes most “learning disabilities” and developmental (i.e., from childhood) delays.

Even if your insurance company has informed you over the phone that you or your child will be covered for speech therapy, due to the specific diagnosis they may reject your claim once you have submitted it. Unfortunately, this is common practice.

Submitting the claim to the insurance company may still be worthwhile. It is best, however, to ask for pre-authorization in writing for any services. Be aware, however, that it can take many weeks before your insurance company will respond to such a request.

If you have the evaluation covered, you should get a statement from your child’s pediatrician stating that he/she is “referring” you for “an evaluation of speech and language.” You should send this to your insurance company together with your letter requesting “pre-authorization” of the evaluation at this clinic.

When we have completed the evaluation, we will send you a full report. If we are recommending therapy, we will provide you with a treatment plan or recommended goals. You will also receive our statement for the evaluation fee, containing the diagnosis code and the procedure codes. You should then have your physician sign the treatment plan, and submit the following to your insurance company:
Your statement.
The treatment plan (signed by your physician).
A copy of the physician’s referral.

Where applicable, your insurance company’s medical claim forms. Be sure that you have entered all the requested information, and that you have asked that the reimbursement be sent to you, not the provider.

If the company rejects your claim, they must give you specific reasons. If speech therapy is specifically excluded from your plan, then this is a final rejection. As we initially pointed out, most commonly speech therapy is included, but only for the results of “medical conditions.” Sometimes, based on the nature of the rejection, we can prepare a letter to the medical claims examiner explaining the nature of the disorder, and the rejection may then be overturned. Please be aware that this is becoming less and less likely. In today’s health care climate, ancillary services are the first to be cut back.

Clients often ask how much of the cost of therapy will be covered by insurance. Some companies cover 50%, others will reimburse up to 85% of whatever fee the insurance company has deemed “reasonable and appropriate.” This is hardly ever the actual cost of the treatment in your geographical region. It may, in fact, be less than half the fee, so that the 80% is actually only 20% of the entire fee.

It is also important to remember that there may be special considerations on your policy. For example, the first visit to a provider may be excluded from payment, or a policy may reimburse only for a specific number of treatment sessions. In the latter case, it is usually required that a progress report be submitted and further therapy be approved. Some policies have a yearly limit on services.

Once the company has agreed to reimburse you for the cost of your therapy, you should send in your receipts on a regular basis (most companies require that you fill out a new medical claim form each time you submit a statement for the same provider), rather than letting statements accumulate and sending them all in at once.

Unfortunately, this entire process can be quite complex and discouraging.  Not to worry.  Here at Lowcountry Therapy, we want to make sure you get the therapy & treatment you need, at a price you can afford.  The points listed above are generalities -- for more specific information on your estimated therapy & treatment costs, call or contact us today.