One of the most difficult things to navigate for parents of special needs children is health insurance coverage. Terms like “medically necessary” and “skilled nursing”, as well as other common health care terms, can be hard to understand and may be interpreted differently by different health insurance companies. This makes it hard to determine coverage and difficult to appeal.
Most families lack the experience and knowledge to negotiate health insurance terms, placing added financial and emotional stress on the already stressful family situation.
While navigating the ins and outs of health insurance is not always a welcome addition to family dynamics, for parents of special needs kids, it's unavoidable. You will be better off the sooner you learn to navigate.
Know Your Policy
When it comes to negotiating and appealing health coverage for your special needs child, knowledge is power. Make sure you have a copy of your policy and have read through it. Asking people at the insurance company won't always get you the most straightforward answers, but the policy terms never lie.
If you need to, ask for extra copies of the policy. You can keep one with you at all times, when visiting the doctor. Keep one at home for reference. You can even obtain a PDF version to keep as a copy on your desktop, laptop, or tablet computer.
Also, know how to access your in-network provider list, and check with all providers (primary or referral) to make sure they are on the list. If not, try to find one that is. If they are not in-network, you will not receive maximum coverage.
Get Help Negotiating
If you are still having trouble understanding your policy, ask for help from an independent source, not from your health insurance company.
Insurance companies want to pay as little as possible while still aligning with the policy terms. This means they will often claim that something is not worded right on a form, and claim ignorance that it was a covered expense.
Work with your healthcare provider, their billings office, and an independent and knowledgeable source to claim your maximum amount of coverage on all items. If you need to, feel free to tell your doctor and the medical billings office exactly how to word certain items for the insurance company.
Of course, you can't commit insurance fraud by claiming something your child didn't get treated for. You are just making sure that the claim is worded correctly for your particular insurance company to cover it properly.
If you still need help, consult with a lawyer who is experienced in defending families against health insurance companies. Many families choose to pay a low monthly or yearly retainer fee for a lawyer, who will then answer all of their questions, and who will be available should the need for lawyer negotiation arise.