ChezPerky

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.

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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)

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I haven't written about all the ups and downs, backs and forths, various changes we've made in the J-man's medications, because, really? What's the point? I'd just be writing the same post again and again. He'll take a new medication for 5, 6, 8, maybe even 10 or 12 days. And then, he'll start refusing to take it. And he'll lose privileges. His beloved Bionicles will go into the attic. His legos will be put away. His rights to use the computer will be taken away. And those threats will work for a day or two. Until they don't work anymore.

But this latest medicaton? Oh my gosh! It's been working so unbelievably well! I didn't realize how incredible life could be until we switched to it! Life was beautiful. But it was an extended release capsule that we had to open up and break into J's food… and, well, THAT didn't go over well. Because the capsule contained these little teeney tiny beads. And the beads… well, J's super-sensitive to food textures. And whenever he decides he doesn't like a food texture, he starts freaking out. So we were putting the beads in yogurt, or ice cream, or pudding, or applesauce. And that worked. For a while. And then we had to start disguising it by putting sprinkles in with the beads. And that really worked. For a while. And that stopped working. And nothing, and I mean NOTHING, was working.

Today he simply wouldn't swallow any bite he put into his mouth. He spat it out. Today was not the day for him to refuse to take his medicine – he had an appointment scheduled with a neuropsychologist to have some testing done. He didn't know about the appointment, so I know his refusal to take the medication today wasn't just acting out to get at me. Plus, he'd told his teacher yesterday that he doesn't like his morning medicine and he's not going to take it anymore. So it's been coming.

I called the developmental pediatrician in desperation at 8am and left him a message. "What do I do? Do I cancel the appointment with the neuropsychologist that I'm paying thousands of dollars to? Or do I put a patch on him and hope that does enough to get him through the appointment? Help!" He called back at 8:30 and told me to put a patch on him. He sounded defeated. I hope he was just tired and rushed. I put a patch on J and tried to get him to calm down. The appointment was at 10am. Plenty of time for the patch to work… Turns out, the new medication works a LOT better than the patch. In comparison, the patch made it seem like he was nearly unmedicated. Sigh.

Sometimes these unmedicated (or in this case, undermedicated) days are a good thing. They give me a sanity check and remind me that the medication (the one he was SUPPOSED to take, but didn't) DOES work. It reminds me that I AM right to be medicating my child, despite how unpopular a choice it is. When I see how out of control my child is, how incapable he is of controlling even his most destructive impulses… it reminds me how desperately he needs the aid of this medication. When I see how crazed and wild he becomes without medication, I am reminded that his behavior was NOT all in my head, that I was NOT making it all up or exaggerating. I was not crazy, or just completely incapable of handling it. It was not normal behavior that I was simply intolerant of. Sometimes the unmedicated days are vindicating.

Today, however, is not one of those good days to be unmedicated. Today, J needed to be focused. Today, J needed to be optimally medicated. Today, J was not. Nevertheless, the neuropsychologist did the best that she could do, and said she'd do the rest at the next appointment in a couple of weeks. She's very flexible and she'll work within whatever limitations she can. And I got to read a good deal of a terrific book: ADHD & Me: What I Learned From Lighting Fires at the Dinner Table. Maybe I'll finish it at the next appointment.

I took the J-man to school and had a long talk with his teacher on the playground. His teacher has the advantage of having an ADHD son of her own, so she can give me a lot of her own perspective on this stuff. And we decided that if the developmental pediatrician is okay with it, we can try moving him to the short acting version of the medication. He already takes the short acting version of the medication on Mondays and Tuesdays at school in the afternoons so that he's focused for speech therapy. He doesn't mind the short acting medication because it's not little beads, it's a pill crushed into powder, so the texture doesn't bother him (…yet). The disadvantage to the short acting version is that it wears off in as little as 3 hours (versus 8 hours), so it has to be given pretty frequently, which means having the teacher give it to him at least twice a day, but she doesn't mind. And so prompted my SECOND phone call to the pediatrician for the day, making my fifth phone call to him in two days. I wish I could have frequent flyer miles with him or something. Sheesh.

And so… That's what we're doing. Switching to the short acting medication, which he'll be taking at 7:30, 11:30, and 2:30 (he'll get the 2:30 dose only on Mondays and Tuesdays… the other days I'll give him a dose when he gets home ONLY if I feel he needs it – otherwise his appetite gets suppressed too much. SIGH.). And really? If anyone thinks this is all too much for a little kid? They should take him for a day. UNmedicated. Because it may be too much for a little kid, but it's DEFINITELY too much for his mommy.

Did I mention I have a full time job in addition to being a full time mommy? Did I mention I'll be working on that full time job into the wee hours of tonight to make up for the time lost this morning trying to take care of him? Did I mention that I DESPISE that people try to suggest that mothers either work full time or they parent full time? I DO BOTH. I am home for all of my triplets' therapy appointments. I take J to ALL of his therapy appointments. I coordinate with all of the teachers, doctors, therapists, psychologists, and caregivers that function as part of J-man's team. I feed them, I shop for them, I love them, I hold them, I parent them. I do all of the things that a full time parent does. And I still have to fit a full time job in between all of that. For that matter, my wondermous husband also is a full time parent and works full time, so don't go thinking he's a slacker either, because he's not. So there.

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Some days I feel absolutely ill-equipped to be a parent of an ADHD child. 

I would elaborate, but really?  Is there anything more to say than that?  I don't know that I was cut out to do this, but then again, I wouldn't trust anyone else to do it better.

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We saw the developmental pediatrician today.  We were going to spend about 10-15 minutes talking about medication and the rest talking about behaviour managment issues.  That was the plan.  But we’ve been trying to sort out the dose on the patch, and not been having QUITE as much success as we’d like, so we ended up spending the entire 50 minute session working out medication ideas.

Essentially, the patch is working really well.  But not exactly the way we’d like.  At the lowest dose the patch comes in, his hyperactivity/impulsivity was still not controlled quite enough.  At the next dose (50% higher), his hyperactivity/impulsivity was totally under control, but he became melancholy, lethargic, disinterested, and sad.  So we moved him to 1 1/4 patches of the lower dose, which is a pain in the neck, but doable.  Unfortunately, we still saw the mood side-effects, though to a lesser degree,  which is just not okay.  It’s very difficult, this balancing act.  It breaks my heart.  I don’t want to lose my vivacious little boy who is so full of life and love and energy and hope and beauty. 

Switching to another stimulant isn’t really the answer, because we’ve been there, done that, and getting him to TAKE it is impossible, plus it would be just like using the patch – they’re all closely related.  We know the patch is working, using more of another stimulant isn’t going to change what the patch is doing at this point. 

So we’re going to augment with another medication entirely and work with that.  We’ll give it a few days and see how it’s going and adjust the dose as necessary.  Dr. S. is going to Ocean City this weekend and into next week.  I feel like my lifeline is going away, even though he told me not to hesitate to call if I needed anything.  I don’t want to call him on vacation.  He reminded me that he knew when he decided that he would not sign over his practice except if he leaves the country, that this means that he gets interrupted on vacation for five minutes several times a day, and he’s okay with that.  Still, I don’t like it one bit.  That being said, we’ll probably NEED to be in touch, since we’re moving into starting a new medication and will need to be monitoring J pretty closely. 

We’re starting at a teeny, tiny, ridiculously small dose.  0.2 ml of the medication (there are 1mg/ml).  I’m hoping we can get J to even take it.  Really, really hoping.

I feel this tremendous responsibility to J through all of this.  I feel like we are manipulating him, in a sense.  I suppose in a way, we are, though we are doing so to help him be able to function in a positive way.  We want him to be able to learn optimally in a classroom, function socially like a normal preschooler/kindergartner, behave appropriate as a  typical  child in society.   We want him to feel like he is in control of his little world, and like he has a positive effect on the world around him.  We don’t want him receiving only negative feedback from  teachers and friends.  We don’t want him to be ostracized for his inability to control his impulses.  Still, this manipulation is a tremendous responsibility.  It’s difficult to know that we’re always making the right judgments.  I wholeheartedly believe that we are doing the right thing by choosing to medicate him, as we are also choosing a behavior management approach in tandem with the medication trial.  I just sometimes wonder if I’m adequately assessing the effects of the drug.  What if I had a bad day and I’m looking at his behaviors through tinted glasses one day?  What if I’m being unfair or biased?  What if I’m not the RIGHT person for this job?

People see me with my triplets and they say, "You must be so tired" or "It must be so hard to parent triplets."  But they never consider that the triplets are the easy part.  They practically parent themselves right now.  But every time I turn around, I feel like I’m doing the wrong thing with J.  What if I accidentally yell at him and scar him for life?  He’s so sensitive.  What if I don’t give him enough positive feedback today?  What if I don’t choose the right routine for him?  What if I can’t find the right scenario to help him control his impulses to avoid the temper tantrum or conflict in the store?  What if I make the wrong parenting choices today?  What if I give the wrong input to the doctor and we choose the wrong medication based on faulty input from me?  What if this has long term consequences that we didn’t know about?

These are the things they don’t tell you about in the parenting manual.  These are the things I’m kind of glad I didn’t know about ahead of time.  If I had, I might have chickened out and missed out on all the fun stuff. 

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