Feeds:
Posts
Comments

Archive for October, 2008

The Punchline

I forgot to include the punchline in last night's post.

My head spinning with visions of CPT codes, diagnosis codes, claim forms, and murder plots, I told Seth he would have to take these claims to EAP which is a whole different process including a whole different set of information.  I would do it myself, except that the EAP office is an hour away from MY office and only feet from his office.

Yesterday, my beloved husband went over to the EAP office for me, armed with copies of all our invoices and claim forms.  He had a lovely conversation with the EAP representative, who was extremely helpful but could not process the claims for him.  Why? 

Oh, see, according to the lovely woman at EAP, the CPT code on these invoices is a – wait for it – medical procedure code.  Since it's not a mental health procedure code, it doesn't need preapproval from EAP, so there's nothing to be done on the EAP side.  This is, apparently, something the medical side gets wrong.  Often.

She called over to the medical claims department and explained that she was sending back these claims and that they needed to be processed and approved.  Needless to say, I'm not holding my breath.

Advertisements

Read Full Post »

There's a lot "they" don't tell you about life.  Especially life with children.  And when you throw in triplets and an ADHD five year old?  Well, there's a whole lot that "they" edit out for fear of you running screaming from the room.  Today's topic?  Insurance companies. Today's blog subtitle?  Don't let the bastards get you down. 

Item the first?  I am *still* getting bills and EOBs for the triplets NICU hospitalization.  Note:  They were discharged from the NICU 1 year, 14 days ago.  I am still getting bills from the company that we rented Ellie's heart monitor for.  I'm getting these bills because the insurance company won't pay for them.  The insurance company won't pay for them because the bills are in Abby's name.  Abby never had a heart monitor.

But that's not what this post is about.  That's just an illustration of how stupid the insurance companies can be. 

Today's post is about ADHD and insurance companies.  You see, when you have a child with special needs, you're bound to run into all sorts of fun with insurance companies.  Insurance companies prefer you to have children who never get sick and who have no special needs.  They make money off of members who pay their premiums and never go to the doctor.  But when you have a child who starts going to a developmental pediatrician, a speech pathologist, a neuropsychologist, and heaven knows who else, well, the insurance company doesn't love you QUITE so much anymore.  

Here's the other fun part about ADHD:  ADHD is considered a mental health diagnosis, not a medical diagnosis.  Insurance companies don't really feel the need to cover mental health diagnoses without a lot of hoop jumping.  I guess they think you might abuse the system or something.  Because my favorite thing to do on a Tuesday morning is go see a therapist, or, say, a developmental pediatrician, just for kicks. 

Oh, and did I mention that most developmental pediatricians don't accept insurance?  At least not the ones in this area.  The ones that do are the ones that are affiliated with large hospital systems, but they have long waiting lists and aren't as good with personal followup.  My doctor is phenomenal about personally following up with everything and I get a call back within hours every time I call him for ANYTHING no matter how trivial.  He coordinates personally with every member of the J-man's team.  I wouldn't get that from any of the major medical centers – plus if I went to them, I'd STILL be waiting to get in for the initial intake appointment because their waiting lists are so long.  So no insurance.  We pay out of pocket, submit the claims to our insurance company ourselves and hope that they will reimburse us. 

For medical claims that are out of network, the insurance covers 60% of the allowable fee.  For mental health claims, the claims must be preapproved by the Employee Assistance Program (EAP), and are covered at 40%.  Mental health claims are also limited to 10 visits per year.  Each invoice includes a diagnosis code (J's is DSM IV's 314.01) and a CPT code (this is a procedure code).  The diagnosis code translates to ADHD, combined type.  The CPT code usually translates to "50 minute office consult", but has occasionally been "school assessment" or other things.

After our first several appointments with the developmental pediatrician, we submitted several claims to the insurance company, not knowing whether it would be covered as medical or mental health claims.  Astoundingly, the claims were covered as medical claims, at 60%.  It was easier than we thought!  Hooray!  After several more visits, and about $1500 in bills, I submitted another pile of receipts and waited.  And waited.  And waited.  And waited.  And waited.  No check.  No explanation of benefits (EOB).  Nothing.  Seth called the insurance company (it only seemed fair, since it's HIS insurance) and they said, "Oh, those claims SHOULD have been processed, but we accidentally denied them saying that they should have been submitted to EAP for preapproval.  We'll re-process them and you'll receive a check in 2-3 weeks."  Three weeks passed and we heard nothing.  So I called them this time, and I had the most infuriating conversation I've ever had in my life:

ME:  I'm trying to find out the status of these claims.
THEM: Oh those claims were denied.
ME:  I haven't received any EOBs.  Can you tell me why they've been denied?
THEM:  We denied them because they're mental health claims.  They need to be preapproved by EAP.
ME:  No, my husband spoke to you a few weeks ago and was told that they were mistakenly denied for that reason, but were being resubmitted for approval because they should have been approved.
THEM:  No ma'am. These are mental health claims, so they have to be submitted to EAP for preapproval.
ME:  I don't understand… in June you approved a claim with the same CPT Code.
THEM:  It doesn't matter, ma'am.  We don't use the CPT code, we use the Diagnosis code.  The diagnosis code on this claim is a Mental Health Diagnosis.  So it needs preaproval by EAP. 
ME:  But the diagnosis code last month was also a Mental Health diagnosis. 
THEM:  But last month, the CPT Code reflected a medication check, so it was a medical claim, not a mental health claim.
ME:  I thought the CPT Code was irrelevant?
THEM:  What is relevant is whether it is a medical procedure or a mental health visit.
ME:  Okay, so the CPT code drives whether it is covered or not, then?
THEM:  No, if it is a mental health diagnosis, it has to have preapproval by EAP.
ME:  You're not making any sense.  June's claims had the SAME Diagnosis code AND the SAME CPT code as this month.  The only difference is that in June you approved the claim and this time denied it.  Can you explain why? 
THEM:  Yes, it was denied because it's a mental health claim.
ME: No, it's a medical procedure, per the CPT Code.
THEM: No, it's a mental health claim, per the diagnosis code.
ME:  You're not understanding me.  Three weeks ago, my husband spoke with you and you explained to him that these claims were accidentally denied, but that they shouldn't have been.  They were to be reprocessed for approval because they should have been approved in the first place.  What you don't seem to be understanding is that you literally owe me thousands of dollars at this point, which prevents me from continuing to guarantee that I can afford appropriate medical care for my child when he needs it.  Can you at least understand where my frustration is coming from?
THEM:  Ma'am, the diagnosis code is a mental health diagnosis code, so the claim needs preapproval from EAP.
ME:  Then why did you approve an IDENTICAL claim in June?
THEM:  The procedure code in June was a medical code.
ME:  The procedure code on these claims is a medical code as well.  That's what I've been trying to tell you.
THEM:  Ma'am, as I've already told you, the procedure code has nothing to do with whether the claim is approved or denied; the diagnosis code drives whether it is considered a mental health claim or a medical claim, not the procedure code. 

I swear to you, I almost threw the phone across my office.  If it hadn't been the middle of the work day, I might have been driven to drink.  Except that drinking leads to more migraines, and that's no fun at all.

Studies show that the stress levels in parents of kids with ADHD are as high as parents of kids with autism.  I believe it, but sometimes I wonder if it's because of the ADHD, or if it's because of the insurance companies.  (It's both)

Read Full Post »

So yesterday, my husband said to me, "Ugh!  Do you have any idea how aggravating it is when you've got a really bad headache and you take medicine for it, and it STILL doesn't get any better? Um.  Wait.  Did I just sound like a total idiot?"  Um, yes dear, I DO have a tiny little bit of experience in that department.  If it weren't so hilarious watching your shoe being shoved so far down your esophagous, I might be slightly irritated at your insensitivity. 

Duh.

Read Full Post »

Abby has this adorable new behavior, she throws these cute little temper tantrums when she's not getting her way.  She throws herself flat down on the ground, screams, pounds her little fists, looks up to see if you're watching her, and then goes back to screaming.  If you're not watching her (or you don't appear to be), she sits back up, wimpers, and goes back to playing, but sulks about it.  It is the cutest thing ever, though I'm sure when she's 5 it will seem less cute.

It's official – Sam is no longer just a baby  – he's a toddler.  But don't go trying to suggest to me that he's not a baby anymore, because he's still my baby, even if he is toddling.  Yes, it's true, he's not just taking one or two steps at a time, he's not just cruising along furniture, he's actually walking 10-12 steps at a time.  And it's not just a fluke, either.  He does this several times a day, then loses his balance and falls on his butt and giggles.  Fortunately, God made little boys with hard heads and soft bottoms for a reason.  Also, diapers are conveniently padded to help in that area.

For that matter, Ellie's not far behind Sam in the toddling department.  She also can take 8-10 steps at a time if she wants to.  She just doesn't want to do it nearly as often as Sam.  More often, she'll take 3-4 steps at a time, fall down and crawl after whatever she's after. Let's face it, my babies are smart, and crawling, for the moment, is more efficient.  They are fast little crawlers, so they're going to get at whatever they have their eye on as fast as they can!  Still, it won't be long before Ellie and Sam are walking, running, and jumping.

And climbing.  Did I mention climbing?  Oh yes.  Sam is a climber.  Abby, too.  They both climb the gates, even the ones that have bars, not holes.  And yesterday, Sam climbed his highchair.  He wasn't in it at the time.  Not good.  The J-man was never a climber, you see.  He was a bundle of energy.  He never stopped moving.  You had to keep moving to keep up with him, but ne never climbed, he never opened drawers, he never pulled things off of shelves or tables, so baby-proofing was a *snap*.  But with these triplets?  They are giving us a run for our money.  Ellie is into EVERYTHING and EVERYTHING is into her mouth.  Sam is climbing EVERYTHING. And Abby will open anything she can.  And they are all super-fast and in three different directions at once.  Still, it's fun.  And cute.  And not nearly as bad as I expected it to be.  We just have a little more work ahead of us to be one step ahead of them!

We know this because yesterday we did something very brave.  We opened up "the baby pit."  We have a living room and dining room that are essentially connected and basically one room.  But we've had the living room surrounded by a baby corral (the SuperYard XT, for those in the know), which has been a great way to contain the babies so that we can turn our backs to clean up after dinner, answer the phone, or even just play with them without worrying about which direction they're all running off into.  It also contained the toys into one discreet space.  The living room/dining room in combination is obviously a much larger space and is easily closed off because the kitchen has a gate, the basement stairwell has a door, the hall leading to the bedrooms has a door, and the doorway leading to the sunroom has both a baby gate and a door that can be closed.  So it can be one big baby pit if we want it to be, which is what we tried yesterday.  And much hilarity ensued.  The babies were SO excited at their newfound freedom.  They could hardly contain their enthusiasm.  In fact, they didn't even try.  They immediately put their minds to discovering all the little things we hadn't yet thought to baby proof.  This was good for us, actually because it gave us a good lesson in what we needed to get done.  No better trial than trial by fire, I say! 

So, I think we may be done with the baby pit.  I'm a little sad to see it go, actually.  But the truth is, they're getting a little too big and a little too active to be contained in it.  They fight over their toys and their space.  My house is really too small to have them contained in there.  And if I need to contain them somewhere, I DO have the sunroom where I can contain them (it's a nice child-friendly space with a foam floor and lots of baby toys, meant for child-containment purposes). 

So, um, anyone need a SuperYard XT?  Actually, I think it was 2 of them that we had  – one of them wouldn't have been big enough.  Sigh.  We spend so much money on this stuff and it's all so temporary, isn't it?  Maybe we'll use it again if I ever get to have that singleton I'm still dreaming of?  But that seems silly.  I mean, we never contained the J-man in a baby pit.  Do people actually contain singletons in baby pits?  Or are they just things that multiples parents use?

Finally, I love Sunday mornings because we get to be a little bit lazy with the timing on breakfast so I always (usually) make pancakes or omelettes or something yummy.  This morning was omelettes, which the babies LOVE (the J-man does too, which is shocking, since he's such a picky eater).  The babies ate TWO omelettes (total of 5 eggs), plus hash browns, plus three bananas.  They are hungry little monsters! 

Afterward, we gave them a bath, because, well, they needed it.  Even though I'm letting them each eat with a fork these days, they still mostly eat with their fingers and there was egg and cheese everywhere.  Sundays are also nice because Seth is home to help me, so I can give them a bath all together instead of three individual baths.  The babies love this, but I have to ask the moms of older triplets – how on EARTH do you manage this??  Were you really able to handle giving a group bath to your one year old triplets regularly?  Could you do it by yourself?  Because my babies are toddling all over the bathtub, in an absolutely hazardous manner and it's nearly impossible to handle them.  Even if I could manage them IN the tub (which I could ALMOST do), getting them all OUT of the tub safely would terrify me.  Can it really be done?  If so, can you tell me HOW?  This is the one thing I've never really managed to figure out how to do.  Are my kids just more excitable in the bathtub than most triplets?  They get SO riled up in the bathtub and go absolutely bonkers.  Is this normal? 

Anywhozit, here endeth my Tales o' fun, because the babies are waking up from their nap.  I hope you all are well – I'm off to snuggle with my precious babies until Seth and the J-man get home from soccer.  Then we've promised to do something SPONTANEOUS today.  I don't know what it's going to be (then it wouldn't be spontaneous, now would it??), but it's going to be SOMETHING, darnit!

Read Full Post »

How Hard Could it Be?

I know I haven't been blogging much lately.  There have been a lot of Jewish holidays in the last month that have gotten in the way of me being able to blog.  But life is back to just it's normal craziness now, so I should be back to somewhat normal blogginess again.

We recently had the pleasure of having a couple over for dinner who is expecting triplets.  We had such a good time, and we got to show off our awesome babies, which is always fun for us.  Most importantly, I hope that we were able to pass along some of the experience that we've collected over the past year and a half through my pregnancy and through parenting these three beautiful babies.   I remember how hard it was to find out I was expecting triplets – it was the last piece of news I ever wanted to hear and I didn't react to it well.  Worse, we got a lot of negative response from people about what we had in store for us on the other end – doctors, friends, strangers. I was terrified of what was coming.  This couple is finding their experience to be similar (though thankfully they aren't hearing the same negativity from their doctors that I heard in the beginning).  Their friends are telling them how hard life will be – that they'll never sleep again, that the husband won't ever be able to travel for work again, that life as they know it is OVER. 

While I acknowledge that life after triplets will never be the same again, I would argue that life after any kids is never the same.  Your priorities shift, your lifestyle shifts, your dreams and desires shift. 

That being said, our lives are not OVER.  We still have fun.  We do sleep.  Frankly?  Life with triplets is an awful lot easier than I ever thought it could be.  Yes, it's a lot of work.  But it's not nearly as much work as I'd imagined it would be.  Even in the beginning when life was all about feed-a-baby, change-a-baby, feed-a-baby, change-a-baby, feed-a-baby, change-a-baby, pump, lather-rinse-repeat, it didn't feel as overwhelming as I expected it to.  Sure, we had moments when we were so tired we would have done just about anything for an extra hour of sleep, but I'd be willing to bet that most parents of singletons feel the same way. 

Seriously, I'm not trying to say that parenting triplets is easy, but the fact of the matter it's all we really know.  We didn't get to know what parenting the J-man was like until he was a year old, so the only babies we've ever had are the triplets, and so they are our only baseline.  Since it's all we know, it's really not that hard.  Seth and I both work full time.  We've got a five year old in kindergarten who has his own activities and appointments.  Seth's gone on business trips, I've survived and done just fine.  We watch movies together (mostly at home, but it's together time).  We've even managed to go out together a couple of times.  We have babies that go to bed at 6:30 like clockwork every night.  We do the things we want to do, we prioritize the things we have to.  But we haven't given up everything.  I'm on my synagogue board, the board of the local parents of multiples club, and I am working with the nurse educator at my local NICU to develop a parent volunteer program.   Seth helps me find time for all of these things and I do my best to help him find time for the things he wants to do.  Our lives are most decidedly NOT over.  I do more now than I did before I got pregnant.  I am more involved in the community than I ever was before.  No, my life is not over – it's just beginning.

The thing is, I was terrified to have triplets.  I thought my life would be over.  I thought it would be too hard.  I thought I would never get out of my house again.  I thought I wouldn't be able to breastfeed.  I thought I wouldn't be able to bond with my babies.  I thought I wouldn't be able to spend time with my children as individuals. I thought I wouldn't be able to go back to work.  I thought I wouldn't be able to sleep ever again.  I thought I wouldn't be able to see anyone ever again. I thought I wouldn't have any fun or enjoy my children at all.

I was wrong about all of these things.  The last year has been so much easier than I ever thought possible.  (I'm sure I'll feel differently when they're teenagers, but that would have been hard even if they'd been different ages.)

Best of all, I've met some of the most incredible women and families in the world because of being a triplet mom – and I feel so lucky for that.  And tonight I got to see some of them, so I'll blog more about that next time! 

Read Full Post »

Calendars are funny things.  The most widely used calendar in the world today is the Gregorian Calendar, which is a solar-based calendar.  The Jewish calendar is based on an adjusted lunar calendar, which sometimes makes it difficult to explain to people why it is that certain dates have significance to me, or why the dates that have significance to me may seem inconsistent at least as they relate to the Gregorian calendar. 

Last Thursday was Yom Kippur, the Jewish Day of Atonement.  The holiest day on the Jewish calendar.  This year, Yom Kippur fell on October 9th on the Gregorian Calendar.  That meant that the date marked two dichotomous anniversaries for me, showing just how far my world has turned around: 

October 9th marked 2 years since I had a miscarriage from my first pregnancy.  I wondered then if I would ever carry a pregnancy to term.  Truthfully, I suppose I should still be wondering that, because technically I haven't yet managed to do that.  But, last year on Yom Kippur, my two daughters were officially given their names.

You see, in Jewish families, girls are given their names in the synagogue after they are born.  The father is called up for an aliyah (an opportunity to bless the reading of the Torah),  a blessing is recited for the health of the mother and the child (in this case, children), and then if the child(ren) is a girl(s), they are formally named at that time.  Boys are named at their bris (usually 8 days after birth, unless their health prohibits it – Sam had his bris when he was about 5 1/2 weeks old)  This can be done on any day that the Torah is read:  Mondays, Thursdays, Saturdays, and holidays.  My babies were born on a Wednesday, so Seth had intended to name the girls the next morning, but I had such a horrific night at the hospital that I'd called him in hysterical tears and he was with me at the hospital instead of naming the girls that morning.  Instead, he named them on Saturday, which was also Yom Kippur, the holiest day of the year – indeed, an auspicious day to name our miracle babies. 

This week is the holiday of Sukkot.  Sukkot is a beautiful holiday – a festival commemorating the 40 years of wandering in the desert and the final harvest.   It is such a joyful holiday that it is referred to as the Season of our Rejoicing.  Sukkot used to be my very favorite holiday.  Everything about it was beautiful to me (well, everything except the esrog, which I'm allergic to).  But two years ago, October 9th fell on the third day of Sukkot, and for that, I'm not quite ready to forgive Sukkot.  This is the funny thing about the way that the Gregorian calendar and the Jewish calendar cross paths.  Which day do I remember?  Both are significant to me.  October 9th also happened to be Columbus Day that year.  Last year, Columbus Day was the day I had my 2 week post-partum check up with my perinatologist.  Somehow, I don't hold Columbus Day in contempt, but I never said I was logical.

Next week are the last of the Fall holidays on the Jewish calendar:  Shemini Atzeres and Simchas Torah.  Two years ago, on Shemini Atzeres, I was back in the emergency room with complications from the D&C from my miscarriage.  On Simchas Torah, I was back in my synagogue, pretending to care about anything there, but hating every second of it.  The singing and dancing with the Torah around me – I hated everyone for being so happy.  I hated the merriment.  I hated the oblivion.  I left that night, angry, sad.  Mostly sad.  Horrified, even.  Last Simchas Torah, my three babies were in the NICU.  Seth was at the synagogue with J, dancing with the Torah, while I sat in the NICU listening to a doctor explain to me that my tachycardic daughter needed a blood transfusion.  Though we'd known it might be coming, we'd had no idea it was coming so soon – if we had, we'd have asked permission from our Rabbi for Seth to carry a pager that day, but as it was, I had no way of reaching him.  So it was up to me to decide that despite the myriad of risks listed on the consent form, none of which would have bothered me in the least bit had I been signing the consent for myself – but all of which terrified me while standing next to my two and a half pound baby – she was to have a transfusion that day.  

Honestly, I'm not sure that I'll ever quite feel the same about Sukkos, Shemini Atzeres and Simchas Torah.  I still love them.  I still rejoice in them.  And there's a great deal of healing to be had in the birth of my three beautiful babies.  I'm very lucky.  But I admit, there's still a taste of bitterness in my heart.  I think it will be bittersweet for a while, but my hope is that the rejoicing of my children in the years to come will ultimately override any remaining bitterness.  Maybe someday I won't feel like my favorite holidays were taken away from me.  Maybe I won't even feel like October 9th is significant in any way.  It's funny how these calendars play tricks on us, you see.   

Read Full Post »

Prehensile Toes

Sam climbing gate 12 October 2008 We have, at various points, called both J and Sam "Monkey Boy."  J because he's constantly jumping around from one piece of furniture to another, much the same way that a monkey jumps from tree to tree.  Sam, because he screeches in much the same way that monkeys screech to get attention and communicate.  But Sam is starting to give us new reasons to call him Monkey Boy and I'm not entirely sure that I like it… he's becoming quite the climber AND he appears to have prehensile toes. 

Please pardon the quality of this picture – I didn't have a real camera handy, so Seth snapped a picture with his cell phone, but this morning, Sam was so very, very clingy and desperate to be held.  I put him down for just a second so that I could get something, and he couldn't handle the stress.  So distressed was he by the abandonment, that he immediately began climbing the gate in an effort to escape his temporary prison.  Can you see his little toes wrapped through the holes of the baby gate?   We are in big, big trouble.  Earlier, he had nearly pushed the entire gate over – that gate is actually one big baby corral around the entire living room and he is so strong and determined that he nearly toppled the entire structure over in an effort to get out and get into Mommy's arms.  You can see that he is quite a determined little beast and will not take no or "just a minute, sweetie" for an answer. 

I was once told that the trick to being a parent is to be able to see all of our children's attributes as positive qualities, even those that on the surface appear to be negative ones.  Stubbornness isn't a negative trait, for example; rather, it will mean that the child will grow up to be a determined individual who will succeed through their ability to stick to their goals even in the face of great obstacles.  This will be my Sam.  He will be an innovator.  He will not be pushed around.  He will get the things he needs and wants in life, no matter what obstacles stand in his way. 

In the meantime, Mommy needs to be an innovator and find a new way to contain him.  But for today, I guess I'll just be holding him a lot. 

(For the record, it turned out he was just very, very tired.  Once I held him for a while, he let me put clothes on him and put him into his crib.  He didn't make a peep and fifteen minutes later when I checked on him, he was snoring gently.)

Read Full Post »

Older Posts »