This summer I had an interesting experience with a major insurance provider. The company initially approved treatment for a 3-year-old client, who I evaluated and diagnosed with severe apraxia of speech. This little guy had maybe five words in his lexicon, all unintelligible to an unfamiliar listener. He could not even consistently attempt to imitate monosyllabic words. His receptive language skills were at least at age level with cognition the same.
After several months of treating him with a motor-planning and sound-sequencing approach, his parents received notification from the insurance company that his treatment was denied because “it was not medically necessary” and his apraxia was deemed “developmental.” The communications stated that my client would “outgrow” his issue in time.
I have been in private practice for almost 28 years and ardently disagree with the insurance company’s reasoning. I consulted with Janet McCarty, at ASHA headquarters, and she provided me with excellent professional advice plus solid evidence to fight for my client. I organized my information then consulted with the family to get their green light to proceed. I went all in to fight this decision with the big insurance company’s medical director.
It became a step by step process to help this medical director understand that apraxia is NOT a developmental disorder, but rather a neurologically based disorder that results in disruptions to a child’s ability to sequence the necessary motor movements to produce speech sounds. My favorite part of this story is when I asked the director how much time I had to discuss my client with him during our peer-to-peer scheduled review, he informed me that “he did not want to be lectured about apraxia because he had Googled it and saw the word ‘developmental’ tossed sporadically around the literature and that was all he needed to see to be convinced that apraxia was not a medical condition with neurological basis.”
I quickly lifted my jaw off my desk, hit my reset button and proceeded to help this “medical expert” understand more about apraxia from this expert in the field of speech and language. While our exchange made some positive impact, he still felt the need to take this case to the next level by calling in a third party pediatric neurologist. I knew that this was going to be a medical professional in my corner. The neurologist and I spoke about my client and I was able to answer specific questions about his treatment and progress. Sure enough, her recommendation was absolutely in favor of this severe speech disorder being neurologically based and treatment medically necessary. She agreed that my client would not outgrow it in time or improve through weekly sessions in small groups.
My point for sharing this story is to say that while it is often frustrating to deal with insurance companies, you have to fight for your clients. When you meet, evaluate, work with a child and their family and you know a child needs treatment, you must advocate and spend the time to fight for this child, no matter how BIG these insurance companies are or how much they try to shut you down.
I need to correct my earlier statement when I referred to my “favorite” part of the story…in fact, my favorite part of this story is that my client, who is now 3.6 years old, was approved for intensive therapy to treat his motor planning disorder. He is making remarkable progress and I am quite confident he can tell Santa what he wants in a complete sentence. Maybe with Mom’s help interpreting, but still excited and able to convey his message!
Lorraine Salter, MS, CCC-SLP, has been in private practice in Reading MA since 1986. She studied and earned both degrees from Emerson College in Boston, after deciding that a career in performing arts was not going to pay the bills. She enjoys the ability to create a strong team for the children she serves through interaction with her clients’ families. You may contact her at firstname.lastname@example.org.