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Thread: What to do when OT and PT benefits are exhausted

  1. #1

    What to do when OT and PT benefits are exhausted

    My daughter has 75 visits with her current health insurance provider. Since Jan. of this year she has exhausted her visits. She is still progressing, she is 7 months post her injury. Have heard that doctor can request more visits. Usually the insurance company will response with 10 more according to a day program coordinator. We will be contacting her doctor with her request. Has anyone encountered this can you tell me what or how you dealt with it?

  2. #2
    Senior Member
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    What my PT once told me was that it was largely a matter of how things were written up. I could no longer go to PT not because I had run out of benefits, but because there was no further "demonstrable improvement." What I was told to do was to leave for awhile and then come back with a new problem, or something that sounded new, such as not being able to get my jacket on or whatever. Insurance companies want to see improvement or goals met, so if a new goal can be established they might go for it.

  3. #3
    Appeal for more visits.
    The therapists can teach her and you alot of the exercises for a home program also.
    CWO

  4. #4
    Senior Member fishin'guy's Avatar
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    Mine was $5,000.00 a yr, that ran out(I actually ran way over as they billed it wrong, to the tune of 3 grand. so I quit, and then about 3 months later my dtr got me into the gym, and at the first of the year it started all over, the between work in the gym was an unbeleivable plus. try getting her back in after the first of the year.(I HATE insurance companies ) People w/ sci should get at least 3-6 months .

  5. #5
    Definitely, try for an appeal. It can't hurt, although there is no guarantee you will win either. If your policy states a limit of 75 visits per year, they aren't under any obligation to pay anymore than that, irregardless of how much it is needed or how much she is benefiting. There should have been better planning, to space them out better, periods of visits alternating with her working on home programs that she had been taught. I ran into the same problem myself when my insurance provider changed. I ended up springing for a few sessions myself, long enough for the therapist to re-evaluate me and get me set back up with a new program to work on independently in the gym that I had joined. I realize however not everyone will have the same financial resources to be able to do this.

    Great news about your daughter! I am guessing she is making pretty rapid progress if she is using up this much therapy!

  6. #6
    Junior Member Julie King's Avatar
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    My husband's insurance had a 50 visit limit, which was almost completely exhausted while he was in the hospital (one day = one visit, so 32 visits were consumed that way). I work for the state, and so I went through the HR office, assembling all sorts of documentation as to why additional therapy visits were essential. After three months (I didn't even follow it, I figured it was a lost cause, given the attitude of the health insurer), the state directed the insurance company to provide unlimited visits through the end of the term. I was stunned. The state, I think, picked up some of the cost, although the crafty insurance company continued to reject claims related to him, and each time I'd fight them, but it does get tiring. It really is like they hope to wear you down.

    Anyway, my point is that you should use any avenue you can and you could be pleasantly surprised. I did try the argument that therapy for him was as much an investment in lowering his long-term health care costs, which the insurer would have to pay. They didn't bite.

  7. #7
    Super Moderator Sue Pendleton's Avatar
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    Julie, if you're near Westminister I'll be posting a new benefit for Marylanders that is free for those over 21 soon. It came down through the Disability Administration and amounts to $2550. a person in heavy duty PT. Still trying to find out if this benefit is for all SCIs or just those at this one place. So check the Mid-Atlantic Forum and Announcements in the next few days.

    Quote Originally Posted by Julie King View Post
    My husband's insurance had a 50 visit limit, which was almost completely exhausted while he was in the hospital (one day = one visit, so 32 visits were consumed that way). I work for the state, and so I went through the HR office, assembling all sorts of documentation as to why additional therapy visits were essential. After three months (I didn't even follow it, I figured it was a lost cause, given the attitude of the health insurer), the state directed the insurance company to provide unlimited visits through the end of the term. I was stunned. The state, I think, picked up some of the cost, although the crafty insurance company continued to reject claims related to him, and each time I'd fight them, but it does get tiring. It really is like they hope to wear you down.

    Anyway, my point is that you should use any avenue you can and you could be pleasantly surprised. I did try the argument that therapy for him was as much an investment in lowering his long-term health care costs, which the insurer would have to pay. They didn't bite.
    Courage doesn't always roar. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow."

    Disclaimer: Answers, suggestions, and/or comments do not constitute medical advice expressed or implied and are based solely on my experiences as a SCI patient. Please consult your attending physician for medical advise and treatment. In the event of a medical emergency please call 911.

  8. #8
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    My insurance would extend them. My PT had to send a letter detailing what we were doing, and how I was progressing. The would extend them a month at a time. They did this for 3-4 months, until the first of the year, when my benefits reset. (Mine was 30 visits per year).
    T7-8 since Feb 2005

  9. #9
    As an OT I agree with all of the above. If there are transfers skills, stengthening skills, reaching skills that can be duplicated by PT, then use your PT benefits for this.
    Definitely appeal to the insurance company and check to see if they would be willing to transfer benefits from something you would not use to the OT.
    I unfortunately question my fellow colleague as to why they did not space out the known number of visits knowing that on paper these are beneifts for the whole year. In addition did they do ANY family or friend training so that some of the treatment could be done at home? There is no way we can get our patients to move forward without them repeating and working on the exercises or treatment in the home setting, Conversely patients don't get better when they only complete their exercises during their therapy sessions.
    You say, "but we can't do some of these activities in the home without equipment?" Well there are a lot of substitute activities that can accomodate the same things without the "gym" equipment.
    If I were you I would contact your case manager at your insurance company to see about conversion of benefits. I would ask the therapist to train in earnest the exercises and activities that can be done at home. I would ask them to provide you with info on reproducing the equipment needed vs an alternatives to the equipment or identifying gyms, senior centers , pools that these exercises could be accomplished. I would also kindly instruct that therapist to look into their patient's insurance so they don't cause this sometime desparate situation in the future. In addition- the actions of this therapist could cause your family member to be stuck without ANY therapy which is a huge disservice caused by your therapist as you have described the situation.
    Lastly- become an expert at your insurance policy (including yours)- you never know when you will need something thhat perhaps your particular insurance may not cover.
    I sincerely wish you the best of luck, and on behalf of my profession I hope you get resolution to this problem so that your family member doesn't get further stressed over this and that they can continue to benefit.
    Take Care, Pam OTR/L

  10. #10
    Junior Member Julie King's Avatar
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    Thanks, Sue! We're in the southern part of the state, western shore. But we'll keep our eyes peeled.

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