A Squeaky Wheel That Finally Got Greased!: HMO decides to cover services for stuttering
by Katie Dauer, Minnesota,USA
For more than six years, I have been attempting to get one of the HMOs in my state, Minnesota, to change their policy excluding stuttering as a covered service.
I tried several different times. Initially I tried to get them to stop excluding stuttering therapy through the Minnesota Speech Language Hearing Association under the third Party Reimbursement committee of which I was chair. At least four different letters were sent. Sometimes there was no response. Other times they indicated that things would stay as they were written. I obtained a letter from a scientist who wrote why it was important to change their policy, input from the committee and again sent this information to the Medical Director of the HMO. We received a very brief letter indicating that they may look at it in the future, but for now they had decided to keep the policy as is.
I own and manage in a private practice in St. Paul, MN which is a small
clinic that sees a significant number of clients who stutter. Until
January 2003, I never billed this HMO because I knew of their
exclusion. In January, I decided to start billing for the services of
clients who had that insurance, believing I would get a denial which I could then appeal. Much to my surprise, I never got a denial on several.. They were reimbursing for stuttering therapy! I was surprised! I suppose I could have continued billing and continued to get paid, but it wouldn't have solved the problem that their official policy excluded the disorder of stuttering, or resolved my ethical unease of receiving payment for services that were officially excluded.
Therefore, I wrote the current Medical director, a new person since my original inquiries years before. Below is a copy of that letter with changes made for privacy reasons. I also sent copies to The Attorney General and the Minnesota Department of Health which oversees the HMO's in MN.
June 2003
Dear [Medical Director]
My Name in Kathleen E. Dauer and I have a private practice in St. Paul that provides speech and language services to many of your members. I am writing this to you to further discuss why XXX needs to consider changing their policy on exclusion of stuttering to a covered service as soon as possible.
First, for several years, The Minnesota Speech Language Hearing Association has asked you to change your policy on the exclusion of stuttering as a covered service. Thus far, you have not done so. I am uncertain if you are aware that all the other HMO's [in Minnesota???] cover this disorder. That is one reason you need to change your policy.
Second, within the last several months, my clinic has been submitting services for stuttering clients to get the denial in writing so my clients could discuss an appeal. Thus far, I have never received a denial. Recently, when I called XXX claims department, they said it was an error that had slipped through the system. An error that had slipped through the system, not on one client but on several, not on one date of services but on many. If it were not for my moral and ethical values, (by calling XXX and pointing out the error), it would never have been caught and you would have paid for stuttering anyway.
Third, rarely do we see a child with just a stuttering disorder. Often times, the disorder is associated with or a result of other disorders such as word finding, articulation and other language disorders which are all covered services under XXX' s policy. Sometimes, a child when first evaluated may just have an articulation or phonological disorder and then as we begin treatment and push their motor system, they begin to stutter which is also a motor problem. At that point in therapy, I would try to establish a fluent foundation for the child and then continue with the articulation therapy. When treating a child with these mixed disorders, it would be unethical for me to not deal with the stuttering along with the other disorders. Because you reimburse speech and language pathologist by the session only and because it is unethical for me to not treat that as part of the problem, the disorder of stuttering is again probably being covered for short periods of time anyway.
Fourth, stuttering is no different in nature than any other disorder you cover. The scientists studying this disorder are finding more and more evidence that it is medical, specifically neurological and genetic in nature.
Fifth, stuttering is a very treatable disorder especially in the young child and the school aged child. If these children are treated by a specialist of fluency disorders like myself, they will be remediated and will not need any further services. If left untreated, it will affect them vocationally, socially and emotionally. Many of our adult clients need psychological services as well as speech services because of all the emotional trauma that they have suffered because of their stuttering. I would assume the psychological treatment would be a covered service, but actually unnecessary if they would have been treated by a specialist earlier in their life for their stuttering disorder.
Because I specialize in the disorder of stuttering, people come from all over the state to receive services. They pay my clinic privately for the services. So your change in policy would not affect my clinic financially. However, it would help your members. For all the reasons listed above, please consider changing this disorder to a covered service for the benefit of all your members.
Sincerely,
Kathleen E. Dauer, M.S., CCC
CC: Attorney General
Minnesota Department of Health
I did receive a letter back from the Medical director and he indicated that their research showed that their coverage policy is similar to that of several health plans and insurers in MN and different from others. He also stated that the Department of Health and the Department of Commerce had approved these documents including the exclusion. He indicated that their policies are reviewed on a regular basis and that they were in the process of such a review and they would consider the speech impediment issue in July of 2003.
After I received the letter, I immediately called the Manager of Managed Care system at the Minnesota Department of Health and discussed the issue with him. He urged me to send copies of all correspondences to him and to urge my clients to forward letters to him as well. Approximately one month later, I received a call from his assistant, who indicated that she had had a conversation with the Medical Director of this HMO and that they were discussing my concern. At the end of August, I received a phone call indicating that the HMO had changed their policy and would now be including coverage of stuttering effective August 15th and they would be forwarding information to participants and members.
I believe this happened for several reasons. One it was good timing. Secondly, I persevered and even through the years when they kept indicating that their policy would remain the same, I kept looking for opportunities to discuss it with them again. Third, I do think that the squeaky wheel gets the grease. I believe it helped to have submitted the services using the correct code, but having them make an error by not denying it.
In conclusion, this was a long, arduous fight, but in the end well worth it. I don't think that I have ever felt as proud as when I received the phone call indicating that a change was forthcoming.
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