October, 2014:

Be an advocate

This summer I had an interesting experience with a major insurance company who initially approved and gave authorization to one of my little 3 year old clients, who I evaluated and diagnosed with severe apraxia. This little guy was just 3 years old, and maybe had 5 words in his lexicon, all unintelligible to an unfamiliar listener. He could not even consistently attempt to imitate monosyllabic words. His receptive language skills were at least at age level. Cognition the same.
After 2-3 months of treating this little guy with a motor-planning & sound-sequencing approach to his speech therapy, his parents received notification from this insurance company that his therapy was denied since “apraxia was not medically necessary” and deemed “developmental.” Their communications stated that this little guy would “outgrow” this communication issue in time. I have been in private practice for almost 28 years, and I can truthfully say that I was ALL IN to fight this decision from the Medical Director of this big engine insurance company. I consulted with an expert, Janet McCarty, down at ASHA headquarters, and she provided me with excellent professional advise and also solid evidence to fight for this little guy. I organized my information, consulted with the family and got their “green light” to proceed, and it became a step by step process to help this Medical Dr. understand that apraxia is NOT a developmental disorder, but rather a neurologically based disorder that results in disruptions to a child’s ability to sequence the necessary motor movements to produce speech sounds. My favorite part of this story is when I asked the Dr. how much time I had to discuss my client with him during our peer-to-peer scheduled review, he informed me that “he did NOT want to be lectured about apraxia because he had googled it and saw the word ‘developmental’ tossed sporadically around the literature, and that was all he needed to see to be convinced that apraxia was not a medical condition with neurological basis.” I quickly lifted my jaw off my desk, and found the need to hit my reset button, then proceeded to help this “medical expert” understand more about apraxia from THIS expert in the field of speech and language. While my conversation and exchange made some positive impact on this individual, he still felt the need to take this case to the next level by calling in an outside 3rd party, Pediatric Neurologist. I knew that was going to be a medical professional in MY corner. Sure enough, this Pediatric Neurologist and I had a chance to speak about this little guy, and I was able to answer specific questions related to his progress with the approach that was being employed in his sessions. Her recommendation was absolutely 100% in favor of this severe speech disorder, apraxia, being neurologically based and medically necessary. He would NOT outgrow it in time, or make any improvements with 1X/week speech therapy in a small group setting.
My point for sharing this story is to say, while it is so often frustrating to deal with these major and minor insurance companies, who only want to hold onto the cash, and not support SOOO many families who pay so much money in their monthly insurance premiums, you have got to fight for these clients. When you meet, evaluate, work with a child and their family and you KNOW that this child NEEDS therapy, whether 1X/wk or 3X/wk, you must advocate and spend the time to fight for this child, no matter how BIG these insurance companies are, OR how much they flex their muscle and try to shut you down.
I need to correct my earlier statement when I referred to my “favorite” part of the story‚Ķ.. in fact, my FAVORITE part of this story is that my little guy, who is now 3.6 years old, was approved for intensive therapy to treat his motor planning disorder. He is making remarkable progress and I am quite confident that by Christmas he will be able to tell Santa what he wants in a long sentence‚Ķ.. mom might need to help interpret it some, but he will be able to talk, and say whatever he wants to say!!!!