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Introduction:
Obtaining insurance coverage for the evaluation and treatment of stuttering can be difficult. Many National Stuttering Association (NSA) members have reported their claims have been denied or their insurance policy did not cover stuttering. The NSA’s Insurance Advocacy Committee was established to help consumers with third-party reimbursement issues.
The goal of this article is to help adults, and parents of children who stutter, utilize their insurance coverage. This paper is based on the brochure Insurance Advocacy and Stuttering, available free of charge at www.westutter.org.
Step One:
The first step is to carefully review your policy. Each insurance plan is different -- and there may be differences depending upon which group you belong to, or which policy was negotiated by your employer. In other words, having the same insurer as a friend or colleague may or may not indicate the same or similar coverage.
Read your policy before your initial evaluation to know if recommended services are covered under your plan. Check with your insurer directly if there is any question about your benefits. Sometimes, even plans that cover “speech therapy” in general will only cover stuttering in particular situations. Unfortunately, just asking if you are covered for “speech” (or even “stuttering”) therapy may not be enough to determine if you are covered for the specific treatment you need. Therefore, when asking about coverage, you might want to inquire as to the most appropriate diagnostic and procedure codes your Speech Language Pathologist (SLP) should use to help assure the codes used accurately reflect the coverage you have.
To reduce confusion, take detailed notes during all discussions with the insurance company. You may receive different information from various people at the insurance company and it will be important for you to have documented information from each of these sources as you move through the process. In other words, always write down the name, date and time of your phone calls, as well as the name, phone number and department of the person you’re speaking with and the exact answer they offer to your query.
Step Two:
The second step in obtaining insurance coverage is usually based on a complete diagnostic evaluation from your licensed and certified SLP. A detailed diagnostic report can help you acquire coverage. Speak with your SLP to ensure the report describes all aspects of stuttering, not just disfluencies produced. This is particularly important as many people experience a significant negative impact from their stuttering. Therefore, your SLP should create a comprehensive report, being sure to report all areas related to stuttering in the report and present a clear-cut diagnosis and treatment plan. Further, it is important that there be supporting evidence for the specific recommendations in the prescribed treatment plan.
Not all children who stutter are appropriate candidates for treatment. The child’s level of motivation, parental commitment, child’s cognitive status and other prognostic indicators should be considered when recommending treatment.
Step Three:
If insurance coverage is denied, the next step is to appeal.
Despite the frustration you may feel if payment is denied, remain objective and informative in your letter of appeal. The primary focus of the appeal is to request reconsideration based on evidence supporting the need for treatment in a concise manner – that will give you the best chance at having the denial overturned.
There are several points to address in your appeal letter:- Stuttering is not an emotional or psychological disorder. Brain imaging studies have shown there are functional and anatomical differences between people who stutter and people who do not stutter, particularly in the speech and language areas of the brain.
- There is a clear genetic component to stuttering. Stuttering tends to run in families and children with family members who stutter are at greater risk for stuttering.
- Early intervention is extremely important for reducing stuttering. The outcomes of early treatment are better than the outcomes of withheld or delayed treatment. The longer a child stutters, the greater the risk of negative reactions which increase the educational, social, and emotional impact of the disorder.
- Stuttering is not a developmental disorder that all children “grow out of.” Children who have risk factors for continuing to stutter are likely to need treatment to obtain a positive outcome.
- SLP services are not merely “educational” in nature. They are recognized as healthcare services by the U.S. Department of Health and Human Services, and by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Moreover, stuttering is classified as a health disorder, with diagnostic codes found in the World Health Organization’s International Classification of Diseases (ICD-9 code 307.0) and International Classification of Functioning, Disability, and Health (ICF code b330).
For more information which you may want to include in your appeal letter, visit the following web sites:www.WeStutter.org
(National Stuttering Association)
www.stutteringhelp.org
(Stuttering Foundation of America)
www.stutteringhomepage.com
(Stuttering Home Page)
www.StutteringCenter.org
(Stuttering Center of Western Pennsylvania)
www.asha.org/public/outreach
(American Speech-Language-Hearing Association) It may also be helpful to view sample appeal letters on the NSA’s website.
The appeals process may include several steps before coverage (or a final denial) is provided. The process may differ from one company to another and you must follow the specific procedures required by your insurer.
Finally, remember that if your appeal is not successful, you still have options. Even if appeals have been filed correctly, some claims will still be denied. Some insurers only cover speech/language disorders that are caused by a medical or neurological condition (brain injury, stroke). Others do not cover any speech/ language disorders at all. In these cases, contact your employer to see if services can be added in the next benefit year. Employers will only view such benefits as a priority if they know their employees want it. You might also meet with your employer during the appeal so they can help you with the specifics of the policy.
If you feel your plan should cover stuttering, or if the plan is not clear in defining which services are covered, you may find it useful to contact your insurance company directly to try to resolve the issue.
Step Four:
If you are unable to find a solution, you may also wish to contact your state’s insurance commission and legislators to file a complaint about unclear language or refusal to provide services the policy states are covered. You can find information about state insurance commissions at www.naic.org. You will need to file a formal complaint, as any other forms of communication may be disregarded. You can contact your local and state legislators through www.capwiz.com/asha/home. For coverage to be improved, employers, insurers, and legislators need to know that such services are a priority.
Miscellaneous Considerations:
Many facilities offer payment options to help those who must pay for their treatment services privately. Some settings offer prepayment discounts that can make treatment more affordable. Non-profit clinics or those run by service organizations often have sliding scales or other reduced-cost options. Check with your SLP and the service facility to see which options may be available.
You might qualify for your state’s medical assistance program. These programs are often based on the severity of a disorder, and are not based on income.
Look for University Clinics in your area that offer quality services provided by supervised graduate student clinicians. These facilities are typically excellent, and often provide clinical services at a reduced price. For children who stutter, therapy is typically available at school. You may have to show that stuttering affects your child’s academic performance. School-based services can serve as a supplement to other clinical speech treatment services if treatment is covered by insurance.
Summary:
Each time you educate people (friends, colleagues, human resource personnel and others) about stuttering, you are helping others who may be in a similar situation in the future.
Successful treatment can help children who stutter achieve goals that might not otherwise have been possible. The NSA will continue to work to improve coverage for stuttering treatment. SLPs, parents, adults who stutter and advocacy groups can have a tremendous impact if we all work together to achieve the same goals.
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