This week’s episode discusses a topic that can cause stress and anxiety for many families. The insurance battle. Where do you start? How do you start? What information do you need? Jennifer and Heidi will walk you through the important steps for starting the conversation with your insurance provider. Deciding to start a tube weaning program is a significant and life-changing event, but unfortunately many families run up against walls that cause them to stumble and give up while fighting for insurance coverage. Parents report that this battle is frustrating, time consuming, and extremely difficult to navigate. At the Thrive by Spectrum Pediatrics Tube Weaning program, there has been an evolution over the last 3 years where more families are able to get insurance companies to pay large portions of the program, if not all of the intensive wean. This is not an easy process though, and at Thrive, we are here to help you through it. In today’s episode, Heidi and Jennifer will break down each step of the process and what you will need to help build your case against insurance. 

You can download this episode from Itunes, Stitcher, Spotify, Google Play, or listen to it below:

Building your case for insurance and working to get coverage for your child’s tube weaning program involves effort and teamwork both with the provider and the family member. It may seem as simple as submitting for insurance coverage before starting the treatment or evaluation, but it is a lot more complex. Over the past 3 years, we have seen a dramatic improvement insurance coverage for families. At Thrive, we feel that this is due to our teamwork with families to help build coverage, as well as our experience with various insurance providers. With this, we have been able to put together a step by step approach to starting your battle with insurance.  

First Step: Coverage 

One of the barriers that people run up against right away is figuring out what the insurance company covers already. By looking at what they already cover, you can find descriptions of what your provider covers for feeding therapy, intensive feeding programs, and other rehabilitative services. This can generally be found online or in the paperwork you have received to identify how they cover “intensives” and what is included. This will help you get an understanding of where they are coming from, what they are looking for in programs, and what they cover now. This can also help to find the limitations and policies that exist around your coverage. This may not be easy to get, but it is possible. 

Second Step: Building the Case 

After you have the information about coverage, it is time to make a case on why the program you are considering is necessary. At Thrive, the first step is to collect information on how to make the case that this program is medically necessary. The evaluation is an investment in getting treatment covered because that is where you obtain all the information necessary to build your case. Many families attempt to get coverage for treatment before the evaluation, but it is almost always impossible to do this. The focus of building the case is to focus on why it should be covered for your child, therefore the clinical information is needed to make the correct argument. Once the evaluation is complete and you know the insurance coverage… 

Third Step:  Cost

Insurance companies are large businesses that are designed to make money. Part of the way that they make money is to build networks of different providers. At Thrive, we work with children all over the United States, and therefore we are typically not in network. If you are working with an insurance company that has a description of intensive, then the case we will help you build is: 

1. Why is it medically necessary for your child to be off the tube? This will be answered and discussed in the evaluation completed prior to treatment. 
2. How does this program meet the criteria for the “intensive feeding program” that your insurance classifies as intensive?
3. If your insurance does not have that description of an intensive, then we will discuss and point out that there is a gap in their network (gap exception/network exception) and need to make the case that this program can fill that gap.  

Fourth Step: Time to Debate

There are several points that need to be made as part of the package that is prepared with you and Thrive. At Thrive, we find it very important to work with families to help submit the insurance package. 

1. Timing: Why now? Why is it medically necessary to participate in the tube weaning program now? 
2. Why this program and not that program? 
3. It is important to point out why another approach that is offered in network may not make sense for your child. We know that most intensive programs use methods like behavioral reinforcement that are shown to complicate a child’s health and relationship with food.  
4. Cost: The facts that certain programs are cost saving needs to be made. It is important to provide evidence that the tube itself is expensive (not for parents, but for insurance) including formula, syringe, and other tube supplies.  
5. A good place to start is your EOB (Explanation of benefits) which can give you some type of idea on the cost of the tube currently (nursing care, supplies, etc.). You can use that information to point out the cost savings for insurance.  
6. When comparing programs, look at quotes for prices of different programs 

It is important to realize that insurance companies are making medical decisions by dictating who people are able to see and what to look for. This is crucial when considering how that impacts you on a personal level. If this is an important and life-changing decision to you, it should not be able to be left to insurance companies.  

An initial no, is not a final no! Almost everyone gets an initial denial, but is necessary to not take no for an answer and continue to dip deeper to build your argument and appeal. The groundwork for establishing this package is a lot of work, but the more work you put in on the front end, the more successful you are at getting it covered. We hope that this process continues to become covered more often!  

Do not hesitate to reach out to the Thrive team at thrive@spectrumpediatrics.com with questions about where to start or starting your tube weaning journey! 

Resources: 

https://www.medicalhomeportal.org/living-with-child/funding-your-childs-special-needs/understanding-your-health-insurance

https://www.medicalhomeportal.org/issue/writing-letters-of-medical-necessity

Prompt Payment Laws: https://www.apaservices.org/practice/business/legal/professional/prompt-pay   

https://www.healthcare.gov/appeal-insurance-company-decision/appeals/

https://www.insurance.com/health-insurance/coverage/appeal-a-health-insurance-claim-denial.html

Patient Advocate Foundation: http://www.thejenniferjaffcenter.org/