Facts, not Fantasy

Tuesday, March 06, 2012

A Photon in the Darkness: Autism and Insurance

I have been very negligent in posting lately, so I plan on setting quite a few posts up in the queue in order to pass along some information to you all.  This particular post from "Prometheus" at the A Photon in the Darkness blog seems rather appropriate, even though the date of the post is a bit out of date.

Autism and Insurance: Myths vs Reality

December 22nd, 2011

Earlier this week, I had arranged to have coffee with a close friend of mine. When I arrived, she was holding a copy of the weekend edition of the Wall Street Journal and was quite upset about an article on the “Affordable Care Act” (”Obama-care”). In this article, it was mentioned that the department of Health and Human Services was planning to leave it up to the various states whether or not to mandate “autism treatment” coverage. This, she felt, was a cruel blow to families with autistic children. Fortunately, I had been through this all before, many years ago, when my child was first diagnosed with autism, so I had some perspective to offer.
Back in those dark days, we were casting about for something, anything to do to help our child, even to the point of attending a “DAN! conference”. In that “conference” (it was more like a revival meeting than a conference), we heard repeated, over and over, that health insurance plans would not pay for anything related to autism, the dreaded “299.0″ (ICD-9 code for autism). As I later recalled, this “fact” was most often mentioned by practitioners who offered “alternative” treatments for autism.
Shortly after returning from that “conference”, I had the opportunity to question (”interrogate” might describe the flavour of that exchange better) our paediatrician about that point. He was - and is - an exceptionally patient person and managed to answer my question without adressing my obvious hostility.
As he explained it, the insurance companies look over each bill and ensure that - among other things - that the procedural code (CPT codes) matches up with the diagnostic code. They want to ensure that a doctor isn’t claiming reimbursement for an appendectomy when the diagnosis is “bunion”, for example. For this reason, chelation and HBOT aren’t “approved” for autism because - as I’ve outlined in several ‘blog postings - they haven’t been shown to be effective in the treatment of autism, just as appendectomy hasn’t been shown to be an effective treatment for bunions.
Other issues that arise, especially in the “alternative” treatment of autism, are when the “treatment” is either of questionable effectiveness, such as “Applied Behavioral Analysis”, or its effectiveness has not been demonstrated. Insurance companies usually see these as “experimental” treatments and refuse to pay for them.
However, parents have also complained that they are unable to get insurance companies to pay for “mainstream” therapies, such as speech therapy and psychiatric consultation when the diagnosis was “autism”. This, according to our patient paediatrician, is due to the ignorance of the practitioner. There is no universal treatment for “autism” - it is too broad and heterogenous a diagnosis for that. So, to justify - for example - speech therapy, another diagnosis is needed, since the diagnosis of “autism” does not, in itself, imply a need for (or benefit from) speech therapy. Experienced and well-trained practitioners are aware of this requirement and so don’t submit bills that don’t have proper justification for the prescribed (or recommended) therapies.
When I later questioned some of the parents who had complained about having insurance companies refuse to pay for “autism”-related treatments, I found that a few things kept cropping up:

1 comment:

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