2 types of vultures and an impending party

Vulture #1:  Literally, a vulture.

See that guy?  He comes with the Fisher Price zoo animals set---each letter has a corresponding animal.  (V is for vulture.)

He also happens to be Maya's favorite animal, for at least the past week.  Today was her 3 year pediatrician appointment, and when the doc walked into the room she proudly held it up and declared "Ehh!!!" 

And so he said "Well, look at that!  Are you showing me your . . . errr . . . "  

So I volunteered "Her vulture.  It's her vulture."  

(It's semi-embarassing and really funny at the same time.  Forget the koala, the penguin, the quail . . . I'm just going to show off this kind-of-ugly-carcass-eating-bird.)


Vulture(s) #2: The insurance people.
I decided to call and check on the progress of my appeal.  I'm waiting to get the verdict in writing before totally losing my mind, but it looks like they are going to deny the appeal based on upholding their position that SLPs are not qualified providers of feeding therapy.  This is ridiculous on every level.  I'm not going to quit. 

Side note one:  Just finding out that it was denied was a 47 minute, 3 phone call process.  The first rep "accidentally" disconnected me.  The second rep tried to find the information and mumbled to herself for 20 minutes before "transferring me to the appeals department, where they would have more information"----but she just transferred me back to the main menu, where I started again.  The third rep told me there's no such place as "the appeals department" but then was semi-helpful.

Side note two: When I type "I'm not going to quit" it looks resolute and determined. Which I am. But when I hung up the phone with the 3rd rep, I turned Elmo on for Maya and sat at the table and cried. It is just infuriating to be so powerless to help fix my situation. I'm doing everything I know to do, I speak intelligently, calmly and forcefully, and it is literally impossible to get anywhere. As angry as I am for me, I'm also angry for the people who are less educated, speak english as a second language, don't have the time to fight, etc. Insurance companies just suck the money right out of them. They're definitely vultures.




In other news . . .


The party prep continues!  Look what Maya helped to make during therapy today . . .

She made the balloons---the cake at the bottom is a wooden sign . . . there's a little heart that says "Maya" that goes in the cake, but I'm still looking for it.

You think I'd crumble? You think I'd lay down and die? Oh no, not I . . .*

A full week of no updates . . . and what do I have to show for it?

This:

Those are the supporting documents that were included in my insurance appeal.  (No, I didn't include 6 packets of blank paper---those ones are just flipped face down due to identifying information).  While I've often alluded to the misery of fighting with insurance, I don't think that I've ever taken the time to really lay the battle out.  Now that our appeal has been finished and sent, I have the presence of mind for some explanation.

I have regular fights debates clarifying conversations with the kind customer service folks over at our insurance company.   Just this week, we had 2 chats:

Monday: I receive 3 denials of claims for pediatrician visits (I tend to save up receipts and then send a bunch at once).  Upon calling and talking to the rep, I explain that I don't think it's possible that we haven't met our deductible for Maya.  He says "well, remember, the amount is not based on how much the doctor bills, it's based on how much we pay out."  I fumble with receipts, sigh, and ask why her vaccinations weren't covered, since the form says "Vaccinations are only included until the patient's 19th birthday."  At this point we realize that all of the claims were processed under my name instead of Maya's, and we have the exact same exchange that I have at some point during Every Single Call to the company:

Him:  Well, ma'am, the doctors office must have made an error in filling out the forms.
Me: Actually, I fill out the forms.  And at this point, I could do them in my sleep.  Are you able to pull up an electronic copy on your computer and verify that there's not a mistake on the forms?
Him: Hold on one second (click clack clickety clack).  Hmmmm.  (click clack clickety clack) Well, ma'am it seems like everything is in order here.  I'm going to just go ahead and reprocess them for you.
Me:  Ok, great.  (eyes rolling until they nearly touch my brain)  Thanks so much for your help.

Tuesday:  While cleaning off my desk (sorting through papers for the appeal) I find an older denial for 2 pediatrician visits.  This time the reason for the denial is "The treatment was given in an inappropriate or invalid place of service"  (yes, that's a direct quote).  And the call went like this:

Me: I'm calling because I think these claims may have been processed incorrectly.
Insurance: Well, ma'am, I'm seeing that they were denied because the service was provided in an "incorrect or inappropriate location".
Me: Well, they were pediatrician appointments. In the pediatrician's office. I'm not sure where else we could have met with him.
(then we looped directly into the conversation quoted above)

Anyway, this appeal was not about these smaller denials---it's about 79 (so far) denials for Maya's feeding therapy.  Maya gets private feeding therapy twice a week, which is invaluable to the development of her muscles and coordination, and is a large part of the reason that she's not still eating jars of baby food (which she was still on until after her 2nd birthday).   To make a 3-month-long-story short, after manymanymany phone calls and re-submissions, we found out that the therapy was being denied because it was being provided by a speech-language pathologist (SLP) . . . to the company, appropriate providers of feeding therapy included pediatricians, GI surgeons, and family practicioners. 

(If I hadn't been in frustrated tears at this point of this particular phone call, I would have burst out laughing.)  For those of you not in-the-know, this is the equivalent of saying "We cover root canals, except if they're done by an oral surgeon.  If you have a root canal done by a manicurist, janitor, or high school principal, we'll totally hook you up."

So my appeal was two fold---providing ample evidence that this treatment is medically necessary and highly beneficial for Maya, and attempting to convince them that an SLP is the most highly qualified provider of this service***.  It was a 45 page appeal, including:  a letter of medical necessity from our pediatrician, a letter of medical necessity from our developmental pediatrician, a letter of medical necessity from our feeding therapist, Maya's first feeding evaluation (at 9 months), Maya's most recent feeding evaluation (at 31 months), a phone call log of all of the discussions that I've had regarding these claims, an Excel spreadsheet of the claims and their pertinent information, 2 documents from 2 different insurance companies that show that they only pay feeding therapy claims to SLPs, 2 research articles that explain why SLPs are the most qualified providers for feeding therapy and explain that their knowledge base is unique and nontransferrable to other types of providers.

Whew.

It's taken me a few months to gather the appropriate paperwork (we couldn't get a letter from the developmental ped until we had our check-up, which takes a few weeks to schedule, etc).  I didn't realize how much having this thing hanging over me was really affecting me (subconsciously) until it was gone. 

It all goes right back to that learned helplessness stuff that I've talked about before.  It's such a downer to have something that you need to do, when you're powerless to get it done.  My to-do list felt insurmountable when I had this deeply subconscious inner dialogue of "Why bother calling that doctor to schedule an appointment?  You haven't even made a dent with the insurance yet."  or "How can you take the time to respond to emails when you should start typing a call log for the appeal?"

So either I would do smaller things on my list and feel guilty about not making appeal progress, or work on the appeal and watch my apartment get messy, take-out get ordered, and a million little things amass on my daily list and fester.

It's so hard to feel powerless.

And I'm so glad that the appeal is done :)

So now the ball is in their court. 

Be sure to stay tuned for a ridiculous update about how it was denied because they are only able to process appeals that are typed in Times New Roman, or postmarked on a Saturday, or whatever.

 ***As an aside, I'm not fully convinced that it actually is their policy that SLPs are not payable---I feel like they may have just been using that as a deterrent in the system to get me to throw up my hands and give up.  They refused to provide me with the policy in writing, telling me that then I could "just commit insurance fraud."  (How?  I'm not sure.)

I realize this makes me sound like a conspiracy theorist, but these people have pushed me right to the edge.  During one call, at 12:27pm the person I had been speaking with said "Ma'am, I'm sorry, I suddenly can't hear you at all---you're breaking up---let me just put you on hold for a minute and then reconnect to see if that helps."  She hung up on me.  When I called back at 12:29 I got a recording: "Thank you for calling.  It is currently our lunch hour.  Please call back after 1:30pm EST.  Thank you." 

Seriously?  It's enough to make anyone go postal.

You live for the fight when that's all that you've got*

(sigh)

I'm feeling a little bit beaten down. 

Friday we had our preliminary IEP meeting.  For those of you lucky enough not to know what that means, here's a quick and dirty summary.  Maya is a special ed student----she will be entering preschool in Sept and needs and "individualized education plan".  When a 3 year old has an IEP, it mainly specifies what type of classroom she will be in (the ratio of kids to adults), what therapies she will get, and other special things she might need (like an aide).

Due to the dire state of Maya's evaluations, I allowed myself to think "This hopefully won't be too bad.  Obviously, she needs oodles of services.  Maybe there won't even be an argument."   I read the reports, highlighted things, had letters from our pediatrician and private feeding therapist, supporting the fact that we need a lot of stuff (just in case), and put together an awesome binder.   I was totally prepared.  I even blew out my hair, so as to look professional and put together.

Yikes.

My faux hawk mullety 'do

Ok, my hair wasn't helping.  But with really strong gel, I tamed it into submission.

I'm not going to give a blow-by-blow recap of the battle that was the preliminary meeting, because I  don't have the emotional stamina.  But here's the summary.

Pro's:  Maya will definitely have a seat in a center based pre-school (it's still up to me to find her a spot in a good school, but the city will approve that spot once I find it).  She will definitely have a one-on-one aide (paraprofessional).  She will definitely get the maximum number of therapy units that are provided by whichever school we go to (each school has their own maximum---for example, one school only provides a max of 2-30 minute PT sessions per week).

Con's:  In addition to the therapy in school, I want her to have therapy outside of school.  The guy in charge of our meeting says no.  He says it's his job to provide us with an appropriate school setting and nothing more.  I say that I want her current level of therapies to be maintained, and that since the school can only provide a certain number of sessions, I want the remainder done after school.  He acts like I'm asking for the moon, I say that this is neither an uncommon nor unprecedented request.  We stare at each other.

The bottom line:  I now have a lot of work to do before the next meeting in April (that's when we'll actually sign the IEP and agree on the preschool and the therapies):

-I'm touring another preschool this Thursday. 
-After that tour, I need to figure out which (of 2 schools) I like better, and schedule a playdate for Maya to go to that school and be screened.  Hopefully we get a school that says that she's a good fit and they will provide her with a spot.
-I need to gather prescriptions, letters from doctors (as many as possible), letters from all of our therapists, progress reports from all of the therapists, and whatever other evidence I can think of to argue for the inclusion of after school therapy in her IEP.
-I probably need to hire an advocate to attend the April IEP meeting with me. (Strength in numbers and all that jazz)

Also, I'm swinging into high gear with putting together our dreaded insurance appeal. 

It's very difficult to feel powerless. 

I know what I'm doing.  My binders are no joke.  The way that I am able to write rationales, organize paperwork, compile data . . . I'm pretty good at it, I think. 

It's rip-your-heart-out-painful and I'm-going-to-go-postal-on-your-azz-frustrating to put together work that's so good you think "How could any rational person argue with this?"  . . .  and just have it met by a pencil pusher who says "Um, no.  End of story.  But feel free to file an appeal if you disagree." (Smug smile and a shrug)

(PRIMAL SCREEEEEEEEEEEAAAAAAAAAAAAAAAMMMMMMMMMMMMMMMMMMM)

In a teary conversation with Dave last night I realized that I need to find a way to compartmentalize this stuff more---to not take it personally when the insurance people send me to another dead end, or this guy says "I'm not going to give you any of that, but we can talk about it again at the meeting in April if you want." 

I have to carve out some sort of zen, centered life, with satisfying and pleasant things, so that insurance appeals, IEP fights, etc (there may be a few other similar battles on the horizon) just become projects-I'm-working-on, and not things that keep me from getting a good night's sleep, and make me cry frustrated tears.

(sigh)

On a lighter note, our OT went to a taping workshop on Monday and now likes to tape Maya up.   Hee hee.

PS-Grab the "My plane landed at Amsterdam International" button if you have a blog or website.  Putting it up does three things: 1. It makes you my new bff, 2. It breaks the ice in sharing some of your experience with your friends/family 3. It helps spread the message to others who may be comforted by knowing their not alone :)

And go round and round and round in the (ridiculous insurance) circle game*

If you "like" us on Facebook, you have been privvy to a few random I'm-going-to-crawl-into-a-hole-and-die-because-I-can't-handle-dealing-with-the-insurance-company rants.

It's got me thinking (more) about all of the bureaucratic nonsense that parents of children of special needs end up dealing with.  Yeah, I know that many people without kids with SN have insurance wars, and many people deal with other bureaucracies . . .but it can become (literally) a full time job for parents of children with special needs.  And, referring back to the learned helplessness model that I'm such a fan of, it's hard to keep trying to fight the shocks.  Last night when Dave got home I took a long, hot shower and had cookies and wine for dinner, because I was ready to just give up.  (Thanks to the KIPP cookie exchangers for providing my dinner ;)  )

If you are lucky enough to not understand what it means when someone says that they're "fighting with the insurance company", or if you don't understand why it would be stressful to just make a few phone calls, I hope that the saga below will help to shed some light:

Background:
Maya gets a lot of therapy, most of which is through the state's Early Intervention program.  However, we also supplement with private speech & feeding therapy, which we pay for out of pocket.  Insurance reimburses us for about 1/3 of what we shell out (don't get me started on the additional expenses of having a child with special needs).  Once we have a statement (EOB) from the insurance explaining what they will or won't pay, we can take money out of our FSA (a special account that we pay into at the start of each year, tax free, and can use only for medical expenses).  Without those EOBs, our money is stuck in the account.  If we don't submit EOBs to use it, we lose it.

The Saga:
I submitted a bunch (60ish) claims back at the end of Sept. Some were processed, some just seemed to disappear (meaning that I never heard anything about them, whether they were approved or denied). I've now spoken to different representatives about these claims a bunch of times---each time "something" is wrong with them, preventing them from being processed at all.

Call #1 : The first time I called, they "didn't have the provider's name and address"---but when I spoke to a representative and explained that all of that information was on the receipts that I sent in she was then (miraculously) able to see it. She then submitted them for re-processing.

My thoughts: Hooray!  That was easy to fix.  Now I'll just wait a few weeks for checks to come in the mail.
  
Call #2: The second time that I called they said that the person who resubmitted them the first time did it incorrectly, so we had to re-do everything from the first call.

My thoughts: Argh!  It's annoying that I waited all this time thinkng that it was being processed!  Oh well, at least now it seems like everything is fixed, and I just need to wait a few weeks for checks to arrive.

Call #3: The third time they said that the problem wasn't the missing address information, it was that they felt like the therapist wasn't qualified to provide feeding therapy (because her letterhead says "speech pathologist"). I pointed them towards 2 other claims that I had submitted and they had paid. She agreed that it didn't make sense, and put them all through for re-submission, again. She said that she would mail me EOBs that said the claims were denied, so that I could submit them to the FSA.  This phone call took 47 minutes, as we had to individually identify each date of service and claim (it's a good thing I've learned to keep good records).

My thoughts: What the hell-o goes on at these places?  How is it even possble that there are so many issues with these claims?  I'm starting to suspect that things are done incorrectly intentionally so that eventually I will give up.  Or be committed to a mental institution.  It's a good thing this girl was so helpful, she'll at least get those EOBs out to us tomorrow so that we don't lose our FSA money.  If I don't get them in the mail in the next few days I'm going to call and check.  


Call #4: The fourth time I called, the person said that we couldn't get EOBs in the mail because our account was now paperless (I'm 100% sure that this is another stalling tactic.  We never changed our account to paperless.  I have statements that were mailed to me in Oct, but in Nov they started posting notices to our "online insurance account"--which I had never even heard of prior to this call.  WHAT THE HELL? ).   She also said that they would never agree to mail 36 EOBs without something in writing. When I offered to fax in something she said that wouldn't work.  Then I had a crying, cursing mental breakdown on the phone and got the supervisor :) I faxed over 50 pages (that I had previously mailed in) to the supervisor. She said that she would try to figure out some way to help.

My thoughts: IswearonallthatiisholythatifiknewwherethisofficewasiwouldbetherecampingoutwithmywhinytoddlerandchangingherdiapersonsomeonesdeskandsingingwheelsonthebusandrowrowrowyourboatallthelivelongdayIfyoupeoplemakemelosemyFSAmoneyIwillcallyou3tmesadayeverydayfortherestofeternity.


Call #5/6/7: The 5th-6th-7th times I called, the supervisor dodged my calls. 
My thoughts: Shocker.  I think they may be starting to realize that I've crossed the line from "Overwhelmed victim of this company" to "Angry and annoying client who won't. ever. stop."

Call #8: The 8th time that I called, the supervisor saw that all of the claims are in the limbo of resubmission (for the umpteenth time). She emailed the manager to see if there was a way to print EOBs for the ones that have been denied and send them to me.  I still don't think that this will help with th 36 claims that are in limbo.

My thoughts:  I'm coming to the realization that the "supervisor" does not seem to be much more capable of getting things done then the call answering folks.  But at least now I have a name, and I get to the same person each time.

Call #9 (today): Supervisor dodged my call

Call #10 (today): Supervisor said that her manager emailed her back, but it was a secure, encrypted emal so she couldn't open it.  So she emailed the manager back and asked her to re-email it but not in a secure encrypted way so that she would be able to open it.

My thoughts: Ok, now you're just making shite up.  There's not even a remote possibility that any of that is legit.

So, there you have it. In my humble opinion, the insurance company is deliberately giving me the run around, trying to wait me out. 

It's maddening. 

Literally.

And every time that I get out my notes and stack of papers to call, I think of one of my old favorite quotes (which you may have seen on the FB page):

"Courage does not always roar.  Sometimes it is the quiet voice at the end of the day saying 'I will try again tomorrow'.- Mary Anne Radmacher

And I guess that's what I'll do.

OH, AND THE 2010 HOLIDAY CARD GETS POSTED HERE TOMORROW!!! HOORAY!!!!

Hungry like the wolf, part 2

Parker is experiencing toy confusion.

This cow is mine

Actually, that's misleading---he is experiencing toy confusion, but not with the cow.  He just likes to cuddle the cow.   The blue car, however, is another story:

Sigh.

To be fair, it's not his fault.  It's Maya's fault.  Maya likes to play with her toys on the coffee table (which we encourage, because then she's standing and bending and twisting instead of just sitting on the floor).  The coffee table is right next to Parker's crate, and now she likes to sneakily load her toys into his bed. 

Exhibit A:

Exhibit B:

Obviously, that's enough to get a puppy confused.  The other night we didn't notice that Maya had put her blue car in the crate, and he slept with it overnight.  In the morning, he woke up with it there and started chewing away . . . and now he thinks it's his.  He'll sniff around her pile of cars, gently lift out the blue car, walk away and flop down somewhere and happily chew to his heart's content.  

At this point I almost feel bad shouting, "Parker!  Leave it!"  . . .  because he looks up at me with such sincere curiosity, it's like I can hear a little voice in his head saying " . . . but it's just my blue car!"

Oh, and Maya thinks it's really funny when he takes her toys.  She'll hold them up to his mouth, and if she can get him to take it (he's so gentle) she starts giggling madly.  So that's helpful.

I am mildly concerned that if I'm not vigilant, we will have a Little People/little animal/little car massacre on our hands.

In other news, I had a hysterical breakdown on the phone with our insurance company today.  I cried, stomped my feet (yeah, that's embarassing but true) and when the representative told me that she "could put in a request for a supervisor to call me back, but they were both busy right now" I got menancingly quiet and say "Oh no.  I'm not getting off this phone.  So you can pretend to be looking up all of these claims, we can talk in circles about my paperwork, or you could just tell me about how your day is going if you want.  But I'm not. getting. off. this. phone."    I hate that so much of my time is spent fighting with people (insurance, agencies, DOT, soon to be DOE) and organizing paperwork in order to fight more effectively. 

It's no wonder my hair falls out.