Regarding the OT issue, he said that it seems that the occupational therapy is being denied because the coverage is exhausted. I asked how it could be exhausted since it says we get 60 consecutive days of therapy and they are denying all of the therapy since January 26th, the day we started OT. He said that the 60 day window for the therapies starts the day of the 1st therapy! Of course, this once again makes no sense whatsoever, and I take it as Aetna just denying everything in hopes that I will go away and they will not have to pay for it. Well, I am not going away and my daughter deserves this therapy. No where does it say that the coverage for each discipline is under one 60 day window of opportunity. Besides, in talking to Aetna representatives, they had mentioned to me the 60 day window ends differently for her speech and physical therapies since she started them on different days. (Not that talking to anyone there has had any weight in the past, but never the less, they had once again led me to believe that I was fine with having the therapies in different time frames.) I realize that they do not cover chronic conditions, but this is ridiculous! What if it wasn't event a chronic condition and a child went through one type of therapy and it was then determined the child needed a different type of therapy? Their policies are just ridiculous. Luckily, he is still looking into it for me and I really hope that they do not continue to deny this coverage. In addition, I am even more bothered that it took them 5 weeks (YES FIVE WEEKS!!!!) to decide that they are denying this therapy and notify the therapy place of this. So, for 5 weeks, I have been taking her to therapy and playing a $50 (what I thought was a) co-pay only to find out that if Aetna does not cover it, I now owe the therapy place over $30 extra for each session that she had once a week for 5 weeks. Ridiculous, capital R ridiculous, I am so sick of dealing with this crap! Based on this problem, I am hoping (and expecting) that once they realize their mistake that they will also extend the time outside of the 60 day window we have for her therapy since I have had to stop the therapy until I have a guarantee that they are going to cover it. I cannot afford to pay any more than I already have for this.
Now onto this crazy issue I have with the out of pocket maximum of $1500 from 2009 being met - or not being met because of a discrepancy in the amount of co-pays I was charged for speech and physical therapy. I spoke with the therapy place office manager this week and she said that I do indeed have a credit with them because of co-pays for certain visits. She gave me a detailed billing today of co-pay amounts that she has credited back to my account for a little over $300. I am so confused over this, it makes no sense whatsoever! I am thrilled to have a credit, (it only is being applied to the money I owe them right now since other therapy is not being covered by Aetna and is still getting ironed out) however it is only applied to some visits and not others. Most of the visits that it applies to are the days when she had two different therapy sessions in one day. Why this would be less of a co-pay than the same two therapy sessions held on two different days is beyond me, it makes no sense, and at this point, I feel like Aetna is playing with the figures, doing some sort of voo doo math to make sure that I did not meet the $1500 out of pocket maximum. If that is not the case, then I need a detailed explanation from Aetna. If this credit is correct, I need a detailing of what exactly each co-pay was and when and why it is a different co-pay for the same type of therapy on different days. I am waiting on an explanation on all of this. If you are confused reading this, that's ok, I'm confused writing it!
If you are reading this for the first time, this is only a piece of the puzzle and the drama that we have been put through. You can see details on this whole insurance debacle with Aetna on my blog: http://bit.ly/Chianna and if you would like to help, feel free to link to the blog and share my story with anyone and everyone who will listen. I am not just doing this for me and my family, I am doing this for all the families who have been wronged by Aetna and other insurance companies who make it their policy to deny claims in hopes you will not notice, make it hard enough to fix problems that they hope you will give up, and state incorrect things over the phone just to get you to shut up and hang up and then they do not stand behind what was said.