In a recent entry I talked about the issues of pseudoscience and the problems with sensory integration theory from an academic and theory-based perspective. Today I got an email from a parent that illustrates the problem from the street:
My child has just been diagnosed with sensory integration difficulties. I must admit the evaluation results are scary and seem overwhelming. I can only imagine what my child is feeling.
I am very anxious to get my child help. We had my child tested at A PROMINENT AND WELL KNOWN SENSORY INTEGRATION CLINIC (name redacted). They are excellent - but the treatment is very expensive and not covered by insurance.
Do you have any experience with how to get the insurance company to make an exception?
It has been recommended that we get 1 hour of weekly therapy for about 18 months and if possible a 3 week summer camp. The hourly sessions cost $165.00
Your response would be appreciated.
Insurance companies see the term 'SENSORY INTEGRATION' and they almost immediately deny the claim - and I DO NOT BLAME THEM! This is why:
First of all, we are occupational therapists, not sensory integration therapists. Most therapists use an eclectic grouping of intervention strategies in order to improve the functional performance of a child. If the accepted purpose of occupational therapy is to improve the functional performance of a child, and if there are CPT codes that correspond to this type of activity, why would OTs feel any need to try to bill using esoteric sensory integration codes that are marginally accepted - even at best??
Second, on what basis can any therapist tell a parent UP FRONT that a child will require 18 months of therapy??? Every child is unique and progress should be measured at regular intervals - I recommend every three months for children with developmental disabilities. If a child is not making adequate progress toward goals then either the goals should be modified or the methods should be changed.
I don't have evidence to support that 3 months is the 'correct' amount of time - it is simply based on common sense and a hope to measure progress at a more reasonable interval.
Some children benefit from long term supportive or maintenance-types of interventions. Insurances are not keen on paying for maintenance - and that is ok. These kinds of costs should be reasonably shared with families or school districts. Generally, for those children who require long term intervention, a good deal of the intervention should be directed toward the family in educating them about extracurricular activity configuration and educational planning.
To firmly state that a child will require 18 months of intervention plus a summer camp is not consistent with what I consider to be appropriate or ethical practice.
In summary, here is my warning to parents and insurance companies:
1. If someone tries to tell you that a child's problem with motor planning, attention, or learning will require a prescribed amount of therapy they are probably making it up. There is no evidence that states that a prescribed amount of therapy is required for fixing any particular problem.
2. It is reasonable to expect that you and your OT will set goals that you agree to. It is reasonable to expect that progress will be measured toward those goals at a prescribed interval that is reasonable.
3. It is reasonable to seek third party reimbursement for OT when problems are likely to remediate quickly. Some children's problems will remediate quickly, or therapy will 'set them on the path' toward changing their activity choices so that problems are not so disabling.
4. Some other children require long term intervention, beyond what can be achieved in short time frames. When therapy is long term, it is because problems are intractable and because there are constantly new issues that require skilled intervention to assist the family or school in developing strategies to work around. It is reasonable for third party insurers to restrict benefits so that therapy doesn't continue without any end in sight. Schools and families should help absorb costs for long term or maintenance types of interventions.
Insurance companies should run for the hills whenever an OT tells them up front that a child requires 18 months of therapy for a specified condition. I believe that is disingenuous. I also have some pretty significant concerns about charging a family $165 an hour. I suppose that there are demographic variations in rates for services but there would have to be some very specific and measurable progress and outcomes to suggest to a family that $165 an hour was worth the investment.
If we used Medicare as a national model of reasonably reimbursed occupational therapy - $165 an hour is FAR BEYOND any Medicare reimbursement for therapy services. WHY would an OT charge a family such a ridiculous rate when the insurance companies don't reimburse anywhere near that rate? Isn't that taking advantage of people who are willing (desperate enough) to private pay?
So here at the bottom of this entry I will post my secondary warning to OTs: if you ever expect to be taken seriously and if you want to insulate yourselves from this kind of criticism and if you want insurance to reimburse for services - please think very carefully about what I have written.