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In-Network Insurance


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Insurance Coverage - Know the facts

 

Be a smart consumer – Know your coverage

While an insurance plan may provide benefits for occupational, physical or speech therapy, the coverage is often very specific as to what they will cover and for how many visits.
Common exclusions and limitations may include:

   Exclusions for diagnoses related to developmental delay or learning disability.

   Speech coverage only for children under three years of age.

   Coverage for therapy only when therapy is required due to injury, stroke, Autism spectrum disorders, trauma or congenital condition.

   A limitation of the number of therapy visits per year or per authorization.

Some plans require a referral and/or “pre-authorization” where the services you wish to receive must be approved by your carrier in advance. This may be required once for the duration your child receives therapy, once per year, or per each block of visits granted.

Many larger companies and institutions with thousands of employees are "self-funded" and set the scope of coverage for their employees. The insurance carriers used by those companies are administrators who merely manage claims. The reimbursements for the claims paid out come from a pool of funds held by that company or institution. The benefits for a particular type of service may be better or worse than the generic plans offered by your plan's third party administrator. The first step in establishing benefits is to speak with your company's HR department to get the correct contact information for your plan's 3rd party administrator.

 

Avoid surprises – Document

Document the date and time of any discussions you have with your insurance carrier or plan’s third party administrator, including the name of the representative you speak with. Having this information carries weight if there is later a dispute over coverage.

Know that when an insurance company representative provides a quote of benefits, it not considered a guarantee of coverage or payment.

Always specifically ask for limitations or exclusions to coverage. When seeking coverage information for multiple services, establish whether limitations and/or exclusions apply to each service or to the group of services.

Establish what your deductible and out of pocket maximum costs, how much of the deductible you have met, and your coverage for the services you are seeking once your out of pocket maximum has been met.

Ask the representative to repeat back to you the facts you believe you have received.

 

Catch problems early – Read your EOBs

An Explanation of Benefits (EOB) is generated for each claim submitted to your insurance company and is your guide to the services you have received, what you were charged, and how much you owe.

You and your provider receive identical information, typically about 45 days after a visit.

It may take some time before payment issues are identified by your provider. If you think you see a problem, contact your health care provider’s billing administrator immediately. You are ultimately responsible for any services not paid by your insurance company.  

 

Know your advocate!

Your HR department manages your health plan and should be your primary resource should you not understand your coverage. What can I do if therapy services are not covered? Check with your HR department to see if they have any special reimbursement programs for either the services being sought or the condition being treated. Call your state’s health/human welfare agency to see if there are any financial assistance programs. LASTS Speech Therapy Services offers a sliding scale fee for families with financial need. Qualification is based on financial ability and a commitment to regular attendance and participation in therapy services. Please ask for a financial hardship packet if you wish to apply, information is kept strictly confidential. 

 

PLEASE BE SURE TO NOTIFY THE OFFICE OF ANY CHANGES IN INSURANCE AS SOON AS POSSIBLE. FAILURE TO PROVIDE THIS INFORMATION IN A TIMELY MANNER MAY RESULT IN FEES FOR SERVICES AND WILL NOT BE COVERED BY YOUR INSURANCE CARRIER.