February 17, 2004 Features

Advocating for Insurance for Young Patients

The lack of insurance for children's speech and language services recently made news in Cincinnati-and prompted one large Ohio insurer to change its ways. Both achievements were celebrated by the Insurance Committee of the Ohio Speech-Language-Hearing Association (OSLHA), which made the victories possible. Katrina Zeit describes how the committee made a difference on the issue of speech services for children in Cincinnati.

At 11 p.m. on Nov. 25, the news anchor for Cincinnati's local Channel 12 opened the late-night newscast by alerting viewers to "a potential crisis for tens of thousands of children"-the rising number of insurers that exclude services that help children communicate. Reporting from Cincinnati Children's Hospital Medical Center, he interviewed a parent about her struggles and successes with insurance, as well as the director and a staff member from the facility's speech-language pathology department. A segment of the newscast showed the child receiving speech and language treatment.

Although the family originally had sufficient coverage of speech services, the parent told the TV audience that when she switched insurance plans, the needed services were excluded. The new insurer informed them that her son's condition did not result from an accident, injury, or illness-and therefore did not meet the eligibility criteria. Her son's speech-language pathologist shared outcomes research with the mother, who filed an appeal with the insurance plan and attended a grievance hearing, where she presented the research. As a result, the insurance plan reversed its decision, and the physician who reviewed the case for the insurance plan sent a letter that stated, "Based on the clinical documentation and appeal information, the decision was made to overturn the original denial of speech therapy. Authorization has been made for the 30 speech therapy visits allowed under your plan benefits."

A Parent's Viewpoint

How was the OSLHA Insurance Committee able to convince a local news station to air the story? As chair of this committee, I had sent out many press releases over the years to local television and radio stations, as well as newspapers, about the need for better insurance coverage, but never had much luck in obtaining responses.

In 2003 I decided to promote the issue from a different viewpoint-that of parents or consumers. I worked with the media relations manager at Cincinnati Children's Hospital, a well-known and well-respected large employer, who helped me frame the story in a way that would entice the media. He pitched it to contacts who might be sympathetic to this type of story. In addition, he advised me how to find the right parent to articulate the story, as success stories are most appealing.

To locate a parent who would be willing to share their story, I e-mailed the more than 80 SLPs at Cincinnati Children's asking for names and received about 10 responses. After reviewing the insurance files for each family and interviewing several parents by telephone, I identified two parents as ideal candidates. Both parents were denied by an insurance plan because of a pediatric diagnosis, and both had won their insurance appeals.

The day after the newscast, I received an e-mail from a manager of Utilization Management for Anthem Blue Cross and Blue Shield. The message informed me that, beginning Jan. 1, 2004, Anthem would no longer exclude speech treatment coverage for developmental delay in its Blues products. The manager stated that Anthem will reimburse for speech services, as long at it is a covered benefit in the contract and the client has not reached the maximum visit limit. (Exceptions included certain self-funded and government products, which require the exclusion.)

A Strategy for Success

Why did Anthem make this policy change? The insurer officially states that the company "realized that many problems arose from the stipulations in place for members with developmental delays. As a result, we made the decision to remove the pre-certification requirement and the exclusion."

I believe that my employer, Cincinnati Children's, also played a role in the decision. For more than a year, I had been attending quarterly meetings between Anthem's Network Management Representative for Cincinnati Children's and members of its Patient Financial Services Division. These meetings are designed to streamline billing procedures between the hospital and Anthem and improve relations in general. Each quarter, Cincinnati Children's collected statistics on claim denials made by Anthem for review in these meetings. Denials for speech and language services appeared every quarter, and the most common reason for the denial was that the patient's diagnosis was considered a developmental delay.

To counter that argument, Ann Kummer, director of speech-language pathology, and I continued to stress that a speech and language disorder will always cause a delay in a child's development, and that many pediatric conditions requiring speech services can be both neurological in origin and considered developmental disorders. We were able to convince the Anthem representative to schedule a separate meeting with Anthem's Utilization Management manager, and we discussed the language of Anthem's speech services benefit in detail. We provided documentation of case examples in which parents received conflicting information from Anthem customer service representatives regarding approval for speech coverage for their child. Often, the confusion resulted from the developmental delay exclusion written in the benefit language.

We asked to receive copies of the marketing brochures and materials that Anthem sales representatives provide to employers regarding the benefit coverage for speech and hearing services, and we requested a meeting with the sales representatives to discuss opportunities for selling a more comprehensive speech treatment benefit. The latter request ultimately was unnecessary because Anthem changed its benefit language to include coverage for developmental delays.

To spread the word of this insurance success to other parents, after the TV newscast I wrote a letter to the editor of The Cincinnati Enquirer. An editor from the newspaper requested that the letter be expanded to article length for publication on the editorial page in the Sunday, Dec. 7, issue. The result was a 480-word piece that explained the limitations of most insurance plan coverage for pediatric speech services and encouraged readers to inform their employers of the need for better coverage. I also recommended that readers obtain a copy of ASHA's Employer Insurance Packet in order to share cost information and treatment outcomes data with their employer.

These insurance advocacy successes have resulted from a close collaboration among management and staff of Cincinnati Children's Speech Pathology Division, members of the OSLHA Insurance Committee, and parents of children with speech and language disorders. I think the keys to our success have been perseverance, capitalizing on the resources and contacts available to us, and collaborating with families who need our services. 

Katrina Zeit, is an SLP and project manager for the speech pathology division of Cincinnati Children's Hospital Medical Center. She may be contacted at katrina.zeit@cchmc.org.

cite as: Zeit, K. (2004, February 17). Advocating for Insurance for Young Patients. The ASHA Leader.

  

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