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Tuesday, July 31, 2012

Autism, therapy and insurance, oh my...

For those who don't know, my younger son (now thirteen) is autistic. He was first diagnosed at the age of four. Although he went from nonverbal to verbal in a very short time, his behaviors have taken years to improve, and he still needs a lot of coaching.

To that end he was referred by his psychologist to a local provider for Basic Skills Training (BST) and Psychosocial Rehabilitation (PSR). Now, this particular provider is not contracted with our insurance; BUT, as our insurance does not provide those particular services, Medicaid was able to pick up the tab once our insurance denied the bill. This continued for about a year.

However - someone decided last November that our insurance *does* provide those services, so they refused to deny the claim, saying we had to go through whomever it was they were contracted with to provide BST and PSR.

Okay, fine. So who is our insurance company contracted with to provide those services?

No one.

There are two providers who do basic assessment and testing and ABA therapy (Applied Behavior Analysis) - things Sean had when he was first diagnosed. He no longer needs to be assessed or tested; we know he's autistic. It didn't go away, you know? He has also progressed far beyond the parameters of ABA therapy which is geared mainly toward nonverbal, younger children.

I have been going in circles for months now trying to get the insurance RN to understand that even though the pediatrician is ordering the wrong thing (first he ordered skills training and development, which didn't work; then he ordered a "consultation" which was even worse), those are not what Sean needs; he needs the BST and PSR continued, please and thank you.

Of course she has to go by what the pediatrician orders, and repeated phone calls to his office have not helped (I guess his staff are as confused as he is).

I tried to get his Medicaid case worker to help, but she was even more confused about the whole thing than the pediatrician's office.

For those keeping score, that's now the pediatrician, the insurance RN, and the Medicaid case worker, all of whom can't seem to figure out how to continue the services he already had, and still needs.

Now I've got his psychologist trying to send a letter to the pediatrician spelling out exactly what it is he needs to order. See, the insurance won't accept her referral; it has to come from the pediatrician.

Meanwhile he's been without this needed service for eight months, and school is starting in a month. He is going to be in eighth grade; big man on campus, both literally as well as figuratively (he's already 6' 1" and weighs over 200 lbs). We can't integrate him into the mainstream classrooms, his behavior still prevents that from working out. On the other hand, he's too advanced to be sitting in the all-day autism room with the children who are much more severely affected. For one thing, their behavior only reinforces his own. More importantly, he's not doing grade level work like he should (and can) nor is he learning how to interact with his "neurotypical peers" appropriately so that he *can* join them in the mainstream classrooms.

This is it, folks. Eighth grade. One last year to help him get up to speed before he enters high school. I want him to be successful, but it seems that everyone is conspiring to set him up to fail.

Okay, maybe not *that* bad, but still... it's so frustrating to have to jump through so many hoops and still get stuck in red tape (to mix metaphors).

Anyone out there with experience in this stuff? Can you see anything I'm missing, something I should be doing that I'm not?

Any and all suggestions are more than welcome. This whole situation has gotten on my last nerve at this point. I don't want to have to get medieval on their hineys, but I'm *this* close to doing just that.