Friday, February 25, 2011

Billing Troubles

I have been talking to the PT and SLP billing people this week. This is the first that I've heard from them about my bills for services since we've been in CDSA since last June. We have been asking for bills for some time and didn't want to get surprised. They are now telling me that the amounts that I understood that I have to pay are incorrect, and that I have to pay more.

My understanding was this: The provider would send the bill to insurance first, my insurance would pay and then I would have a copay. Then, based on my sliding scale, CDSA would pay a % of that copay and I would pay my %. In 2010, my copay was $25 and my sliding scale was 40%, so my understanding was that I would be responsible for $10 per session. In 2011, we upgraded our insurance to the more expensive plan (specifically because of these therapies) and our copay is now $20, so my understanding was that my copay for this year would be $8 per session.

The therapy groups say this is incorrect, and I am being charged $19.55 per SLP visit and $15 something for PT (I haven't seen the PT bill yet). They are telling me that they bill to insurance first, then when the BCBS payment comes in they bill the *remainder* to CDSA (not the BCBS copay, but the total amount minus the BCBS payment), and then CDSA determines their allowable and pays their % and I pay my %.

The actual breakdown of charges/payments on my SLP bill (for a 2010 session) are:
Charge from provider $100
BCBS payment $19.37
CDSA payment $29.33
Family owes $19.55
Write off $31.75

My interpretations are:
Total BCBS allowable $44.47
Total CDSA allowable $48.88 (I owe 40% of this)
Total collected by provider $68.25

My questions:

1) What is the actual way that my share is computed, and why is it different from what I thought? This was apparently not adequately explained to me in the beginning.

2) How can the provider collect more than the BCBS contracted allowable rate after billing through insurance? BCBS pays them based on the allowable charges, and I would think they are not allowed to try to collect the balance (besides the copay) after filing it through insurance. It seems to me that by billing BCBS, they are agreeing to the BCBS allowable amount, yet somehow through this arrangement they are able to collect 1.5 times the BCBS allowable amount. If I was not working with CDSA, they would not be able to collect more than the allowable rate from me. If my CDSA sliding scale rate was 60% instead of 40%, would I be asked to pay $29, instead of the lower BCBS copay? That makes no sense.

3) What is the CDSA allowable based on? Is it affected at all by how much my insurance pays? Will my amount owed per session actually change at all for 2011 due to my change in insurance level? BCBS is paying an additional $5 to the provider now (lowering my "copay" from $25 from $20), but will this just end up being another $5 for the provider? Will it just decrease my actual payment by $2 (40%)?

4) If I was not going through insurance at all, what would my payment be through CDSA? If I have to pay $20 for the session, and my BCBS copay would be $20 anyway, what is the benefit of my going through both CDSA and insurance? I might as well just go through my insurance alone and pay the $20, or go through CDSA alone. In that case, I wouldn't have to worry about whether the providers are on my insurance or not (such as the CLC therapists), or about running out of visits with my insurance.

5) Why must it take so long to discover how much I actually owe? We have been with CDSA for 9 months, and I am just now starting to see bills and discovering that my bill is double what I expected this whole time.

Tuesday, February 22, 2011


I visited CLC yesterday, the inclusive daycare that our CDSA coordinator suggested we look into. Overall it seemed fine. I wouldn't say it wowed me, but it is a 5 star center. It's in an older building that wasn't built to be a daycare. The windows are pretty high, so the kids can't see outside. The playground is nice enough with a slide with a ramp and steps, and a tricycle path. The director seemed very knowledgeable about special needs, and seemed to have a very nice relationship with the kids and staff. They prefer that we use their therapists, but we aren't sure if they are covered by our insurance. I asked about cloth diapers, and she said they haven't had a kid in cloth since 1994! But she said she would look up the requirements and she was sure we could work it out. She also said it would be possible to start Sweets for 3 days per week when she turns two, and then switch her full-time once Munchkin starts kindergarten. That way we could secure a spot before the August rush, and not have to send Munchkin to the home daycare without Sweets.

In other news, I thought we were going to have the OT eval yesterday afternoon, but it turned out to just be paperwork. The coordinator seemed really flaky, and I felt like I had to be on top of everything. We were having a meeting about OT, but she forgot to even have me sign the OT papers until I asked. She didn't get anywhere with getting the speech therapist to agree to 1 hour sessions, but we might get two 45 min sessions at least.

Friday, February 18, 2011

A long chat

Yesterday I had a long chat with our CDSA coordinator.

1- We originally asked for one 60 minute speech session per week, but the speech therapist said they only do up to 45 min sessions. Instead, she suggested we could do two 30 min sessions per week to get the full 60 mins. This was approved by CDSA and is what we have been doing. Unfortunately, it means we have to pay double the copay, one for each visit. Apparantly, it also means CDSA has to pay double. Our coordinator wanted to switch back to once per week. I explained to her that I had asked the speech therapist a few weeks ago if she thought we should move to once per week, but her opinion was that she thinks Sweets really needed the full 60 minutes per week. I don't want to give her less therapy just because of money if her therapist thinks she really needs more. In the end, the coordinator agreed that we would do one of two things. A- Get the therapist to do one 60 minute session per week, even though she says they don't do that. B- If we are going to do two sessions per week, make them 45 min sessions, since it costs the same to us either way. So, either way, we'll be getting more therapy for our dollar.

2- The coordinator wanted to know what the PT is working on with Sweets, because she thought that Sweets had met her PT goals. We talked some about her PT goals, such as #7 - "Will have advanced motor skills so that she can go across uneven surfaces and eventually be able to run" which I don't think she's met. I know that the PT takes her outside to walk on the grass (uneven surfaces) and that they also work on steps. This week, the PT said that they worked on the ladder to the slide, and that Sweets should be able to climb up and help pull herself up with her arms, but that she isn't doing it. The PT and I have also noted that Sweets can walk well, but that she is still unsteady and falls down a lot. I wonder if she has balance issues, or if she is just over-confident right now. The coordinator asked some questions about sensory issues because that can lead to balance problems, but I haven't noticed any sensory issues.

3- The coordinator sat in on the DT session yesterday. She noticed that Sweets is interested in the shape sorter, but is not really able to do it. She recommeded an OT eval. I didn't really think fine motor was an issue for her, but I don't mind having an eval to check it out. We scheduled it for Monday, since I'll be home with the kids for Presidents Day.

4- We also talked about whether the home daycare environment is going to continue to be the best option for Sweets. Right now, except for Munchkin 2 days per week (and Munchkin will be in kindergarten starting this summer), Sweets is the oldest kid there. The other two babies are 10 and 18 months younger than Sweets. The boy who was 6 months older left 4 months ago, leaving Sweets without a real peer role model. Particularly because of her delays, it would be good for her to see other kids model age-appropriate behaviors. The coordinator believes that now that Sweets is getting older and is walking, that the balance may be ready to tip from the benefits of the small group home care (which is great for an infant) to the social interactions with peers. I think that I agree with this.

My original thought was that we could send her to TLS, where Munchkin goes, but the coordinator suggested we look into another center, CLC. CLC is an integrated center for kids with special needs and typical children. I am familiar with this concept because Munchkin was at PK as an infant (where we met our home daycare provider), which was the same way. They try to keep a 50/50 balance between kids with an IFSP/IEP and without. They have a therapy room and their own therapists on staff. This center also has a contract with the public schools so that if Sweets qualifies for a developmental classroom (once she is 3) then the public schools would pay her tuition at this center during the school year and we would only have to pay for summers. They have two classrooms there with spots for 12 kids in each, with one lead teacher and two assistant teachers per class, so nice ratios too. CLC goes age 2-5, so we could theoretically move Sweets in 2 months at her birthday if we wanted to. It seems most practical though, to start her there when Munchkin starts kindergarten, esp because Munchkin would still be at our home daycare 2 days per week until then (she doesn't have a full-time slot at TLS). If Munchkin gets into year-round school, it would be very convenient, because CLC is right next door and even shares a parking lot with that school! I will be taking the tour at CLC on Monday, since I have off for Presidents Day. I didn't even know about this place until yesterday, but it sounds really good so far!

Tuesday, February 8, 2011

New signs

Sweets has learned some really useful signs this week: HELP and HURT. She has actually been doing HELP for a little while now, but we just figured out what it meant. She clasps her hands together in front of her and then moves them up and down repeatedly. But now we have figured out that it's her way of signing HELP, and that is a really useful sign! She uses it all the time now! She also learned HURT this weekend. She fell down and got hurt on Friday night and I showed her the sign. Then when she fell down on Saturday, she used the sign to show me! It was awesome (the signing, not the hurting of course!). She also learned to sign BERRY this weekend, though she signed it better on Saturday morning than she did on Sunday and Monday. She is starting to pick up signs really quickly now, and it's so nice for her to be able to tell me what she's thinking! On Monday she signed CHANGE to me to tell me she wanted a new diaper. I layed her down on the hardwood floor to change her, and she signed COLD to tell me the floor was cold! It's just so nice to be able to get this level of communication from her!