Some New Wins!

November 23, 2011

We recently won two more very significant appeals of the denial of ABA therapy under self-funded insurance plans.

In the first case, the insurer had a very clear exclusion barring coverage for ABA therapy.  The exclusion was stated in a self-funded plan covering an New York-based employer.  After submitting the claims for the client, receiving the denials, going through the appeal process, we finally wound up submitting an appeal directly to the employer’s insurance committee.   In that appeal letter, we pointed out some ambiguities in the coverage and in the exclusion, explained why ABA therapy is medically necessary to treat autism, backed up our assertion up with clinical/research and documents supporting the fact that the therapy had been effective in treating our client’s child.  Despite the exclusion, we won the appeal – the employer directed the insurer to pay all of the clients ABA therapy claims, which exceed 50K in therapy costs!

In the second case self-funded case, the employer was based in Illinois.  The client/employee had previously submitted ABA therapy claims to the insurer under a psychotherapy code and the claims were reimbursed/paid.  The client later became concerned about whether the insurance payments were erroneous because the insurer later insisted during a telephone call that the policy excluded coverage for ABA therapy.  Upon review of the plan documents, we noted that no such exclusion was included in the plan.  The client pointed out the issue and   asked for clarification from his human resources department.  He was advised that the proper coding and related issue of reimbursement for ABA therapy under a psychotherapy code was in a “gray” area.  At our encouragement, the employee asked and was allowed to submit a letter to his employer in support of coverage explaining why ABA therapy was medically necessary to treat children on the autism therapy and why the terms of the policy would compel coverage for such therapy.  We drafted the letter for the employee, who submitted it with supporting documentation.  After considering our input, the employer not only agreed to cover the employee’s past ABA therapy claims (previously submitted as psychotherapy), the employer amended its plan to cover the company’s other employees for ABA therapy, up to a 36K limit per year.  What a fabulous victory!  

Needless to say are thrilled with both results!

The Take Away:  Push back and bring appeals on self-funded plans even when the insurer says there is an exclusion or denies coverage.

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