Blue Cross Blue Shield: Cover therapy treatments for Reed

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Our 4 year old, Reed, has experienced developmental delays in all areas since he was an infant. A recent brain MRI has shown some neurological abnormalities. He has received speech, physical, and occupational therapies since he was a year old. He initially received therapy services from our local Early Childhood Intervention program, but began receiving private therapy services at the age of 3. He has made steady progress with consistent therapy, but it is anticipated that Reed will continue to need therapy over the years to reach his full potential.

Last year, Reed was on a BCBS PPO insurance plan through my employer that covered all of his therapies through home health. He is now on a different BCBS PPO through my husband's employer as of August 2018. From August to October of 2018, this insurance plan covered a home health agency coming to Reed's daycare for his therapy. This allowed him to receive therapy while my husband and I both worked full time in order to make enough to cover the cost. Although the therapy was "covered," we are required to pay the full cost until we meet a high deductible.

BCBS has recently denied more therapy visits for Reed stating that they have a policy of only covering home health visits for children who are unable to leave their house. When the therapy company asked to see this policy in writing, BCBS has been unable to produce it.

During a peer to peer review with Reed's doctor, the insurance company said they would cover the visits if the home health agency billed them as "not in the home." However, BCBS has a contract with the home health agency stating they must bill the therapy as being in the home. So BCBS asked me to tell the therapy company to do something that they have a contract with the therapy company stating that they cannot do.

Just 3 months ago, they covered his visits through home health. They are now trying to force us to take Reed to an outpatient facility if we want his therapy visits to count towards our deductible. We are unable to do that without one of us significantly reducing the amount we work, and therefore, our income to be able to pay for these therapies until we meet the high deductible.

I believe this is a move by BCBS to keep us from meeting our deductible so that they will not have to do their part and begin paying for services once the deducible is met. They are enacting "policies" at random and suggesting billing changes that they know the therapy company cannot do as part of a game to avoid providing coverage.

Home health is not solely for children who are unable to leave their homes. I am a home health speech therapist myself and none of the 20+ children I have worked with over the past year have been confined to their homes. Various insurance companies, BCBS included, have covered services for these children so that they could receive therapy and their parents could continue to work or be available to care for other children in the home while therapy was done.

Additionally, BCBS has imposed a 60 visit limit for all therapies. This means that they will only allow a few months worth of therapy to count towards our deductible. It will take 47 visits for us to meet our deductible. Then BCBS will cover 13 before we will again be responsible for the full cost. Reed needs consistent, year-round therapy for years to come. Visit limits are based on the therapy model for adults recovering from strokes and brain injuries where they receive intensive therapy over a short period of time. It is RE-habilitative. Therapy for children is habilitative. They are not recovering lost skills, but gaining them for the first time. That requires more than just a few months of therapy.

The combination of denying home health and an unreasonable visit limit will bankrupt our family or force us to not be able to get him the help he needs. We are not looking for a handout but just asking BCBS to provide the health coverage we are working hard to earn and pay for. Reed has been making good progress with therapy and deserves the chance to gain the skills he needs to succeed in life. Please help us appeal to BCBS not only for Reed, but the thousands of other families being put in this position by these "policies" that insurance companies use to avoid meeting their responsibility to cover services.