We had a speech eval at Duke this week, for another opinion regarding apraxia. Or just for another opinion in general on what could be going on with Sweets. We were there for about 2.5 hours and while Sweets was shy at first (understandably), I think that she got comfortable and performed well for the eval.
First off, this SLP does NOT think that Sweets has apraxia. She said that there are too many things that don't fit. She said that maybe as she gets older she may show more signs of apraxia, but right now she doesn't. She also said that Sweets is doing so many good things that she feels really good about her progress, and she thinks that we have a good chance that Sweets will just "catch up" by the time she's 5, with therapy and hard work, of course. So that is very encouraging!
She did a test called REEL-3, which is a different test than what we had last week. On this test, there is a series of yes/no questions. The first number is based on when she gets 5 "Yes" answers in a row, and the second is based on when she gets 5 "No" answers in a row. For some reason, and oddly, Sweets actually scored lower on receptive language than on expressive language on this test. Neither the SLP nor I felt that this accurately describes Sweets, but that's just the way the test came out this time. She said that once she is 2.5, they could do a different test on her that might be more accurate. It seems like everyone uses a different test and it's just whatever test they like - not very "standard" at all.
~~~~~~~~~~~~~~~~~
REEL-3
Receptive Language: Raw Score 45 | Age Equivalent 16 months | Ability Score 78 |
%ile Rank 7%
Expressive Language:Raw Score 48 | Age Equivalent 20 months | Ability Score 85 |
%ile Rank 16%
Language Ability Score = 78
Scale:
90-110 Average
80-89 Below Average
70-79 Poor
<70 Very Poor
~~~~~~~~~~~~~~~~~
I told the SLP about the recommendations from the EI eval, regarding using the picture boards and focusing on 20 words. She said that she didn't want to say that she disagreed with the other SLP, but that it's definitely not what she would have recommended. (Sounds like she disagrees to me...) She said that she does use picture boards for kids who can't/don't sign, but that since Sweets can sign that she wouldn't have recommended a picture board for her. She also said that she would continue to work on all vocabulary with Sweets. She said continue to sign and say the word together, and encourage her to try to do both as well, instead of just signing. She does this sometimes, but often she just signs. Our usual pattern is that she signs, I ask "Do you want XXX?", she signs again while approximating XXX. So we are to try to get her to do the approximation up front and prompt her with less. So instead of saying the whole word, I can try to shape my lips, or look at her expectantly, to give her the idea that I want her to say it. Gradually over time, of course.
She did demonstrate this technique with Sweets, and Sweets responded to it pretty well. She even got Sweets to say "On" which I have never heard her say before. This is a meaningful new word because it is a VC (vowel consonant) word, and all of her others are CV sounds, particularly CVCV words where C1V1C1V1, ie Mama, Dada, ByeBye, PeePee, NightNight (NiNi).
In the end, I felt a little confused because the two evals differed so much in their assessments and recommendations that it makes it hard to know what to do. It is looking like Sweets does not have apraxia, though we don't know what she does have either yet. Or if she is "just a late bloomer" after all this.
Thursday, May 26, 2011
Monday, May 23, 2011
May speech evals
Sweets had her CDSA eval last week for speech. The SLP said that there are some features consistent with apraxia, but others that are not. At this stage, she didn't rule it in or out. We will have our Duke eval this week, so I'm curious whether they will say anything different. I have heard before that she may be too young to really be able to tell because she only just turned two. The good news though is that her receptive language seems fine, and her cognitive tested within average range this month too. Her expressive language is also not bad, in that she can sign to communicate (and she is learning new signs rapidly!). Her speech skills tested at 9-12 month level.
The CDSA eval SLP suggested making a list of about 20 words that Sweets would want to use frequently through her day, and working on those specifically, aiming for consistency and accuracy. So a more focussed approach instead of a broader approach. She also suggested that she could make us a set of picture cards for those words, one for home and another for daycare, to help Sweets identify what she is saying to us. That seemed like a good idea at the time, but as I think about it more I'm not really sure what that will give us, considering that Sweets can already sign all of those words (and a lot more) to give us a cue for what she is trying to say. What advantage would picture cards give us over the signing that she is already doing?
The CDSA eval SLP suggested making a list of about 20 words that Sweets would want to use frequently through her day, and working on those specifically, aiming for consistency and accuracy. So a more focussed approach instead of a broader approach. She also suggested that she could make us a set of picture cards for those words, one for home and another for daycare, to help Sweets identify what she is saying to us. That seemed like a good idea at the time, but as I think about it more I'm not really sure what that will give us, considering that Sweets can already sign all of those words (and a lot more) to give us a cue for what she is trying to say. What advantage would picture cards give us over the signing that she is already doing?
Sunday, May 15, 2011
Sure Step!
Our Sure Steps have arrived! I took Sweets for her fitting on Friday for her new SMO orthotics. The Sure Steps are made especially for her based on the measurements the orthotist took on her a few weeks ago. We got the flowers and bugs pattern and they are definitely nice. We also bought the Sure Step shoes to go with them, because I had heard that it can be hard to find shoes that fit over orthotics. These have a wide toe box and wide heel to accommodate the orthotics, and there are two insoles that are removable to fit with or without the orthosis.
We arranged the payment so that the insurance will be billed first. They will charge us a deductible (around $300-350) and then they cover 60%. What's left will be charged to the state early intervention, and they will pay 60% of that. In the end, I expect that we will have to pay about $150, but we'll see how it ends up.
I expected Sweets to fuss when we put the Sure Steps on for the first time, but she really didn't at all. She even seemed to like them right away! The orthotist showed me how to put them on her feet, pushing her big toe up and to the side to get her heel in deeply. The velcro strap is supposed to be pulled tight - "Snug is not enough" - so she made a mark on the outside so that we would be sure to pull it to the right amount.
SureSteps on, without shoes
SureSteps on with shoes
She is supposed to wear them for 1 hour the first day, 2 hours the next day, 3 hours the next day, etc until after 1 week she will be wearing them full-time. Today is day 3 and she seems to do really well in them. She is walking well, and best of all - she isn't falling down a lot! The reason we got them in the first place is because Sweets pronates her feet when she walks, causing her to fall down frequently. These are supposed to help with that, and they seem to already! They should also help her learn to run and climb.
We arranged the payment so that the insurance will be billed first. They will charge us a deductible (around $300-350) and then they cover 60%. What's left will be charged to the state early intervention, and they will pay 60% of that. In the end, I expect that we will have to pay about $150, but we'll see how it ends up.
I expected Sweets to fuss when we put the Sure Steps on for the first time, but she really didn't at all. She even seemed to like them right away! The orthotist showed me how to put them on her feet, pushing her big toe up and to the side to get her heel in deeply. The velcro strap is supposed to be pulled tight - "Snug is not enough" - so she made a mark on the outside so that we would be sure to pull it to the right amount.
SureSteps on, without shoes
SureSteps on with shoes
She is supposed to wear them for 1 hour the first day, 2 hours the next day, 3 hours the next day, etc until after 1 week she will be wearing them full-time. Today is day 3 and she seems to do really well in them. She is walking well, and best of all - she isn't falling down a lot! The reason we got them in the first place is because Sweets pronates her feet when she walks, causing her to fall down frequently. These are supposed to help with that, and they seem to already! They should also help her learn to run and climb.
Wednesday, May 4, 2011
Developmental Eval - cognitive
Today Sweets had a developmental eval. The eval was done at our home and took about 1.5 hours. By the end, Sweets was just not interested in participating anymore. I was surprised that she did the 3-piece puzzle (she usually has a lot of trouble with that), but she would not even really try the 9-piece puzzle. She just got up and walked away! LOL The evaluator did a test where she hid a toy under a washcloth to see if Sweets could find it. At first she found it every time. But when the evaluator hid the toy, and then moved the washcloths, Sweets failed to find the toy every time. There was also a part with matching pictures, which Sweets participated in but failed every time.
The evaluator used the Bayley Scales test again, which is what we had last year too. This time, she scored a 90 for cognitive! Yay! Last time she had scored an 80, which is borderline delayed, but a 90 is within average range! We are very excited about that, because as long as she can understand things, even if she can't speak, she can still learn to communicate in other ways. She's already communicating well using sign language, and I know there are many other communication methods too. Sweets was also scored for social/emotional and scored at 93, but we weren't really concerned there. She did not get scored for PT, adaptive, or speech because she recently had a PT and OT eval, and she has a speech eval coming up this month.
The evaluator used the Bayley Scales test again, which is what we had last year too. This time, she scored a 90 for cognitive! Yay! Last time she had scored an 80, which is borderline delayed, but a 90 is within average range! We are very excited about that, because as long as she can understand things, even if she can't speak, she can still learn to communicate in other ways. She's already communicating well using sign language, and I know there are many other communication methods too. Sweets was also scored for social/emotional and scored at 93, but we weren't really concerned there. She did not get scored for PT, adaptive, or speech because she recently had a PT and OT eval, and she has a speech eval coming up this month.
Monday, April 25, 2011
upcoming IFSP review
I was speaking to our early intervention coordinator about Sweets' upcoming IFSP yearly review. We decided to have her evals before the IFSP review to have a better idea of where she stands before making new goals for her. She will have a developmental eval, and also a speech eval. The coordinator brought up apraxia to me, not knowing that I am already looking into it, and suggested that they can eval for that. I updated her about how the SLP didn't think that Sweets could really be diagnosed with apraxia until closer to 3, and how my ped said they could do the eval at Duke at age 2 so we have a Duke eval scheduled. She said that CDSA can do an eval for apraxia too, so we are thinking we will do both and have a 2nd opinion on this. I have also asked the SLP for more information on what she thinks fits or not about apraxia for Sweets at this point and am waiting on an email back on that. Unfortunately, the SLP will be out of town for our IFSP review, and will miss it. Considering speech is her biggest issue, that is a shame, but she will give a report for the IFSP before she leaves.
We also had Sweets measured for SureStep orthotics. I had the impression from the PT that it would cost around $150, but that is way off - it is more like $1100! Some of it is covered by insurance, and CDSA will also pay some, so hopefully in the end we'll only have to pay under $300, but I still don't know how much.
We also had Sweets measured for SureStep orthotics. I had the impression from the PT that it would cost around $150, but that is way off - it is more like $1100! Some of it is covered by insurance, and CDSA will also pay some, so hopefully in the end we'll only have to pay under $300, but I still don't know how much.
Thursday, April 7, 2011
speech and apraxia
The only words that Sweets has that are really pretty clear and that she uses in context are Baby, Dada, and PeePee. Sometimes Bye-bye, sometimes Mama, but those require prompting. For other words, she will sometimes make an approximation sound, but it requires prompting. For example, she signs MORE, I say "You want more? More, More, Say More", and she will say "Muh". Words that begin with M, D, or B, she will usually do that for, just saying "Muh" or "Duh" or "Buh" with prompting and after signing. She also says "Buh" for Up. Sometimes we think she is trying to say "Love You" but it sounds like "Ahh Ooh" and we aren't sure. Some words she really tries to say, but they come out like just a garbled mess, like Shoes and Cheese. And those are about all the things she says. She will repeat more individual sounds with prompting if she is in the right mood for it (including "FFF" and "Puh" and "Lah"), and she will babble various sounds together as well. She also frequently makes a "Digga Digga Digga" sound in her babbling, which I don't think means anything, or if it does we don't understand it. Perhaps she is too young for the apraxia evaluation because she doesn't really have enough words to look at a picture and say what it is?
She knows about 40-50 ASL signs and communicates pretty effictively with sign. She's had her hearing checked twice. She will turn 2 this month.
We have signed her up for CLC, the inclusive special needs daycare, for this fall. Sweets will be be under CDSA until age 3 before going under the county school system. If she qualifies for developmental classroom on her IEP at that time, then the county will pay her tuition at CLC. I'm not sure if I can expect that she would qualify for that though.
She knows about 40-50 ASL signs and communicates pretty effictively with sign. She's had her hearing checked twice. She will turn 2 this month.
We have signed her up for CLC, the inclusive special needs daycare, for this fall. Sweets will be be under CDSA until age 3 before going under the county school system. If she qualifies for developmental classroom on her IEP at that time, then the county will pay her tuition at CLC. I'm not sure if I can expect that she would qualify for that though.
Tuesday, April 5, 2011
Apraxia?
Sweets has her appointment next week to get fitted for the orthotics, so that ball is rolling. Sweets made a big jump in abilities around 18-19 months, but now is pretty stable again. I can't say she really has many more words than she did 3 months ago, and she isn't really saying them any better than she was. The only notable addition to her vocabulary is "pee pee", though she will attempt to repeat certain sounds and words with prompting. She does have some more consonants - her newest is the "F" sound. She has at least 40 signs though and picks them up more easily and uses them in context, and another 10 or so that she is trying. She will sometimes combine two signs, such as DRINK MILK, to tell us what she wants. With prompting, she will say the first sound of a word with the sign ("duh" for done, "muh" for more or milk, etc). She will sometimes look right at you and babble something, giving you the impression that she thinks she is telling you something specific. She is doing pretty well at identifying body parts now (or at least face parts). She can follow 2 step directions. She had an OT eval because she can't do the shape sorter or chunky puzzles, but she can do the piggy bank just fine, so they concluded that it is more of a spacial reasoning issue than an OT issue.
Over the weekend, I happened to be at a party with a pediatric neurologist from UNC and we talked some about Sweets. Of course, Sweets wasn't there, and she didn't see her clinically, but she gave me some things that I might want to look into based on my description. One was developmental coordination disorder. I looked that up and I'm not so sure she is *that* uncoordinated, but the doc said that it often presents with apraxia of speech as well. I looked up apraxia of speech and that sounds more like Sweets to me. It's hard to really know anything just from looking on the internet though. I asked Sweets' speech therapist what she thought about apraxia, and she said it is certainly a possibility for Sweets but that she wouldn't feel comfortable diagnosing apraxia at this age and would wait until she was 3. On the internet (again...) I have read several accounts of 2 year olds diagnosed with this though. I emailed the person who did our Duke speech eval about this and she said that they can test for it at 2. I would like to find someone local who is experienced with evaluating for this. It doesn't have to be at Duke, if there is someone else more suitable.
Her 2 year WCC is coming up this month, but I didn't know if I should ask the sub doc about this since she doesn't really know Sweets. Our regular ped will be out on maternity leave, but I am emailing her about it now.
Over the weekend, I happened to be at a party with a pediatric neurologist from UNC and we talked some about Sweets. Of course, Sweets wasn't there, and she didn't see her clinically, but she gave me some things that I might want to look into based on my description. One was developmental coordination disorder. I looked that up and I'm not so sure she is *that* uncoordinated, but the doc said that it often presents with apraxia of speech as well. I looked up apraxia of speech and that sounds more like Sweets to me. It's hard to really know anything just from looking on the internet though. I asked Sweets' speech therapist what she thought about apraxia, and she said it is certainly a possibility for Sweets but that she wouldn't feel comfortable diagnosing apraxia at this age and would wait until she was 3. On the internet (again...) I have read several accounts of 2 year olds diagnosed with this though. I emailed the person who did our Duke speech eval about this and she said that they can test for it at 2. I would like to find someone local who is experienced with evaluating for this. It doesn't have to be at Duke, if there is someone else more suitable.
Her 2 year WCC is coming up this month, but I didn't know if I should ask the sub doc about this since she doesn't really know Sweets. Our regular ped will be out on maternity leave, but I am emailing her about it now.
Wednesday, March 16, 2011
Potty!
I have been thinking for a few months that Sweets may potty train pretty soon. She signs CHANGE when she wants you to change her diaper, or will even go fetch a clean diaper and bring it to you. She also signs DIAPER and POTTY. She has been going for long stretches between wet diapers, and even wakes up dry from nights and naps more and more fequently. Munchkin potty trained right around this age too - she was in unders full-time during the day the week of her 2nd birthday. Sweets will turn two in 6 weeks.
When I first mentioned to my husband that I thought Sweets might be ready to potty train soon, he was pretty skeptical. He said "She's late doing everything else, I don't know what makes you think she's going to potty train." I just took the baby potty out from storage and showed it to her. Some time later, we were talking about Sweets' delays, and my husband said that he feared that we would start to expect less from her, and that she would therefore do less. I said, you mean like potty training? After that he was 100% supportive of potty training!
So I brought the baby potty into the living room and we have been leaving her naked from the waist down at home more often. She has been sitting on the potty at diaper changes, but she hasn't "done" anything in it yet. That is up until last night!
She was in the bath and started signing POTTY and frantically making noises - "Mmmmh! Mmmmh!" I didn't want her to potty in the bath, so I took her out and dried her off and sat her on the potty. She sat, but didn't go. When she stood up, she held her knees together and grabbed her crotch and made the frantic "Mmmmh! Mmmmh!" noises again. Then she sat and stood up and repeated the noises. This cycle went on for about 20 minutes interspersed with some playing. It was like she knew she had to go, but she didn't really know what to do about it and was trying to hold it in. Eventually, she got so frantic that I sat her on the potty and played "If You're Happy And You Know It" with her to occupy her hands and try to keep her still. And when she got up, there was a big poop in the potty!
We worry about her cognitive abilities, because she still doesn't succeed at the shape sorter or simple puzzles. But she can communicate many things through signing, which shows us that she understands language and remembers the signs and knows how to use them. So maybe she will be able to potty train just fine, despite her other delays!
When I first mentioned to my husband that I thought Sweets might be ready to potty train soon, he was pretty skeptical. He said "She's late doing everything else, I don't know what makes you think she's going to potty train." I just took the baby potty out from storage and showed it to her. Some time later, we were talking about Sweets' delays, and my husband said that he feared that we would start to expect less from her, and that she would therefore do less. I said, you mean like potty training? After that he was 100% supportive of potty training!
So I brought the baby potty into the living room and we have been leaving her naked from the waist down at home more often. She has been sitting on the potty at diaper changes, but she hasn't "done" anything in it yet. That is up until last night!
She was in the bath and started signing POTTY and frantically making noises - "Mmmmh! Mmmmh!" I didn't want her to potty in the bath, so I took her out and dried her off and sat her on the potty. She sat, but didn't go. When she stood up, she held her knees together and grabbed her crotch and made the frantic "Mmmmh! Mmmmh!" noises again. Then she sat and stood up and repeated the noises. This cycle went on for about 20 minutes interspersed with some playing. It was like she knew she had to go, but she didn't really know what to do about it and was trying to hold it in. Eventually, she got so frantic that I sat her on the potty and played "If You're Happy And You Know It" with her to occupy her hands and try to keep her still. And when she got up, there was a big poop in the potty!
We worry about her cognitive abilities, because she still doesn't succeed at the shape sorter or simple puzzles. But she can communicate many things through signing, which shows us that she understands language and remembers the signs and knows how to use them. So maybe she will be able to potty train just fine, despite her other delays!
Monday, March 14, 2011
orthotics and more, updates
We just had another PT eval and Sweets tested at 20 months for Stationary (37%), 17 months for Locomotion (5%) and 18 months for Manipulation (16%). Her overall gross motor is 10%. Her PT said that she thinks that the type of test that was used judges her more harshly than where she really is though.
Her balance is quite poor though, and she falls frequently. The PT has recommended that we have her fit for orthotics for her feet because she pronates when she walks - turns her feet to the edge, which affects her balance. The orthotics would fit in her shoe and would prevent her from rolling her feet. The PT thinks that we will probably get Sure Steps, but the orthotist will make the final call as to what kind would be best.
Sweets also had an OT eval last week because our coordinator saw that she wasn't able to do the shape sorter when she observed a recent developmental therapy session. In the OT eval, Sweets was able to pick up pennies off the floor just fine and put them in the slot in a piggy bank with either hand. The assessment showed that her problem is not really with her fine motor skills as much as with her cognitive skills. She doesn't perform the shape sorter or puzzle well because she doesn't know where the object should go, not because her hands can't manipulate it properly. So, she doesn't need OT therapy, and will just continue with the developmental therapy with a new goal of working on problem solving toys and helping her persist to her level of abilities without giving up.
Our speech visits are going up from two 30-minute sessions per week to two 45-minute sessions. It costs us the same either way, so that's nice.
We have been dealing with a conflict regarding the billing for the therapies. We started 9 months ago and this is the first time we've gotten a bill for anything, and we really had to harrass them for it. But when I got it, it was not the amount that I expected, it was about double. I called them up and told them they did my bill wrong, and they said that I was the one who was wrong. Both therapy agencies did it the same way, so I was thinking that they must be right and I've been wrong this whole time about how much this was going to cost us. I complained to my early intervention coordinator and after 2 weeks they got back to me and told me I was right and the agencies were wrong and they were going to make sure they fixed it for me. So that is nice. I wonder how many people they are messing up the bills on that don't even realize. They were basically double billing my insurance and the state for the same amount, so that they were collecting about 1.5 times what they should.
We are going to run out of insurance-covered therapy visits. We only get 75 per year (increased over 50 last year because we upped our insurance option) and we are using 3 per week now. She actually gets 4 per week - 2 speech, 1 PT, 1 developmental - but the developmental is free for us. So we are going to go off the insurance for a while and just pay out of pocket so that we don't use up all of our visits right away. Right now we are still on a 40% sliding scale rate, but we think that will go up next time they re-evaluate us in June, so we figure we should pay the out-of-pocket now rather than later.
We are still looking into the developmental preschool for her, but we are finding that their therapists aren't on our insurance, so that is a complication. They say that we CAN use our own therapists, but they really think it's better if we use theirs.
Her balance is quite poor though, and she falls frequently. The PT has recommended that we have her fit for orthotics for her feet because she pronates when she walks - turns her feet to the edge, which affects her balance. The orthotics would fit in her shoe and would prevent her from rolling her feet. The PT thinks that we will probably get Sure Steps, but the orthotist will make the final call as to what kind would be best.
Sweets also had an OT eval last week because our coordinator saw that she wasn't able to do the shape sorter when she observed a recent developmental therapy session. In the OT eval, Sweets was able to pick up pennies off the floor just fine and put them in the slot in a piggy bank with either hand. The assessment showed that her problem is not really with her fine motor skills as much as with her cognitive skills. She doesn't perform the shape sorter or puzzle well because she doesn't know where the object should go, not because her hands can't manipulate it properly. So, she doesn't need OT therapy, and will just continue with the developmental therapy with a new goal of working on problem solving toys and helping her persist to her level of abilities without giving up.
Our speech visits are going up from two 30-minute sessions per week to two 45-minute sessions. It costs us the same either way, so that's nice.
We have been dealing with a conflict regarding the billing for the therapies. We started 9 months ago and this is the first time we've gotten a bill for anything, and we really had to harrass them for it. But when I got it, it was not the amount that I expected, it was about double. I called them up and told them they did my bill wrong, and they said that I was the one who was wrong. Both therapy agencies did it the same way, so I was thinking that they must be right and I've been wrong this whole time about how much this was going to cost us. I complained to my early intervention coordinator and after 2 weeks they got back to me and told me I was right and the agencies were wrong and they were going to make sure they fixed it for me. So that is nice. I wonder how many people they are messing up the bills on that don't even realize. They were basically double billing my insurance and the state for the same amount, so that they were collecting about 1.5 times what they should.
We are going to run out of insurance-covered therapy visits. We only get 75 per year (increased over 50 last year because we upped our insurance option) and we are using 3 per week now. She actually gets 4 per week - 2 speech, 1 PT, 1 developmental - but the developmental is free for us. So we are going to go off the insurance for a while and just pay out of pocket so that we don't use up all of our visits right away. Right now we are still on a 40% sliding scale rate, but we think that will go up next time they re-evaluate us in June, so we figure we should pay the out-of-pocket now rather than later.
We are still looking into the developmental preschool for her, but we are finding that their therapists aren't on our insurance, so that is a complication. They say that we CAN use our own therapists, but they really think it's better if we use theirs.
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.
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
CLC
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.
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!
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!
Friday, January 28, 2011
21 months - 10 words, 25 signs
We count 10 words that Sweets can "say" now at 21 months:
Baby = "Bee Bee"
Bye Bye = "Ba Ba"
Cheese = "Gzzzh"
Dada = "DaDa"
Done = "Duh"
Hi = "Ha"
Mama = "MaMa"
Night Night = "Ni Ni"
Uh-Oh = "Oh Ah"
Up = "Buh"
She has 25 signs now that we count:
BYE-BYE
HI
MILK
MORE
DONE
EAT
FINISHED
BATH
DIAPER
DOG
NO
YES
DRINK
BOOK
WAIT
UP
BABY
BED
CHEESE
PHONE
CRACKER
SHOES
SOCKS
COLD
POTTY
Baby = "Bee Bee"
Bye Bye = "Ba Ba"
Cheese = "Gzzzh"
Dada = "DaDa"
Done = "Duh"
Hi = "Ha"
Mama = "MaMa"
Night Night = "Ni Ni"
Uh-Oh = "Oh Ah"
Up = "Buh"
She has 25 signs now that we count:
BYE-BYE
HI
MILK
MORE
DONE
EAT
FINISHED
BATH
DIAPER
DOG
NO
YES
DRINK
BOOK
WAIT
UP
BABY
BED
CHEESE
PHONE
CRACKER
SHOES
SOCKS
COLD
POTTY
new coordinator
Today I met our new CDSA coordinator. Our old one moved to a different county. She seemed nice. I felt like she hadn't read Sweets' file though. I had to tell her our whole history. She didn't know that Sweets got other therapies, or that we needed a new developmental therapist. She asked if we thought we even needed to keep getting developmental therapy, and I said that we wanted to keep it, and at least it can't hurt. So now she's on top of getting us a new therapist and I should hear from her Monday about that. She said she wanted to have Sweets re-evaluated though to see if she still needed it. She offered that they could do the eval after her 2nd birthday, because the expectations go up at that point, making it more likely that she would test as delayed. I think that she would test as delayed anyway, but I guess that's a good idea.
I also asked about moving speech therapy to once a week for 45 minutes, instead of twice a week for 30 minues. We have to pay copays each time, and we only get 75 therapies per year on our insurance, so we don't want to use them all up now. But the therapist said that she thinks we should stick to 2x30 minutes because she thinks Sweets needs the full 60 minutes. So, we'll do that. I don't want to be cheap about it, if that's what she needs.
I also asked about moving speech therapy to once a week for 45 minutes, instead of twice a week for 30 minues. We have to pay copays each time, and we only get 75 therapies per year on our insurance, so we don't want to use them all up now. But the therapist said that she thinks we should stick to 2x30 minutes because she thinks Sweets needs the full 60 minutes. So, we'll do that. I don't want to be cheap about it, if that's what she needs.
Wednesday, January 26, 2011
New therapist... again
I was happy that we were getting a new developmental therapist because I wasn't crazy about the old one. We saw the new therapist last week for the first time and I liked her. We had the session at our house because it was MLK day and we were off work, and I think it worked nicely to have it at home. So, now I just got an email from the new therapist that she found another job with another agency. So now we have to find *another* new therapist. And meanwhile, with all the confusion, Sweets has only had developmental therapy twice in the past two months. :(
Friday, January 14, 2011
No diagnosis
My Sweets has global delays in motor, speech, and maybe cognitive. It's a little hard to measure cognitive without speech. The doc said that if she was just delayed in one thing, they wouldn't worry about it because kids tend to learn one thing at a time. But since she has global delays, that is more concerning. She had her first steps and first words both around 18 months though, and has been really doing a lot of new things since then, so we are seeing a lot of progress now. The big question then, is whether there is something medical going on, or whether she is "just a late bloomer" as so many people like to tell me.
We've had a bunch of tests, including a karyotype (test for things like Down Syndrome), blood tests for muscular dystrophy and thyroid problems, evals for autism and neurology, and everything has tested okay so far. The most recent test was a DNA microarray which tests for small scale DNA copy number variances, and that just came back normal as well. So, we have no answers, but since everything is testing negative, and she is starting to do a lot of new things, we are now on a watchful waiting program and not testing anymore for now. The docs say that even if she were diagnosed with something, we are already plugged in to the early intervention therapies that we would need to get anyway, so the diagnosis isn't as important for now. But a diagnosis could be important later, in order for her to keep getting services once she ages out of early intervention. Or, she could be just a late bloomer and she will catch up by then anyway.
We've had a bunch of tests, including a karyotype (test for things like Down Syndrome), blood tests for muscular dystrophy and thyroid problems, evals for autism and neurology, and everything has tested okay so far. The most recent test was a DNA microarray which tests for small scale DNA copy number variances, and that just came back normal as well. So, we have no answers, but since everything is testing negative, and she is starting to do a lot of new things, we are now on a watchful waiting program and not testing anymore for now. The docs say that even if she were diagnosed with something, we are already plugged in to the early intervention therapies that we would need to get anyway, so the diagnosis isn't as important for now. But a diagnosis could be important later, in order for her to keep getting services once she ages out of early intervention. Or, she could be just a late bloomer and she will catch up by then anyway.
new developmental therapist
We are getting a new developmental therapist next week. We talked to the agency, and the boss said that she had received several similar complaints about this therapist and that she was actually going to reassign all of her clients to other therapists and let her go. So I guess I wasn't the only one who felt that way. The boss said that she didn't want us to feel just okay about our therapist, she wanted us to really love our therapists and think they are great. And I do think our other two therapists are really good, it was just this one that I didn't feel super warm about. So, we get a new one next week!
In other news, the speech therapy is going really well! I'm very happy with the therapist now. We are seeing a lot of new signs and sounds since we started. The physical therapist sees a lot of progress and says she thinks Sweets will graduate from PT some time this spring or at least before her yearly eval in June.
In other news, the speech therapy is going really well! I'm very happy with the therapist now. We are seeing a lot of new signs and sounds since we started. The physical therapist sees a lot of progress and says she thinks Sweets will graduate from PT some time this spring or at least before her yearly eval in June.
Monday, December 6, 2010
neurology
We had a neurology appointment and while the doc said he didn't see anything really concerning in Sweets' exam, he did order a blood test for a microarray. She has unexplained developmental delay, so I guess it's possible that this test might detect a reason behind it.
Friday, December 3, 2010
child led therapy?
We have a developmental therapist who I don't really love, but I don't think she's necessarily bad either. I just think that she's not very child-led, and therefore misses opportunities to make the therapy more enjoyable for Sweets. I don't sit in on all the sessions, so maybe things are different when I'm not there too.
Example: Last time, she had it on her agenda to work on stacking with blocks. Sweets was not really interested in doing that and was trying to play a mimicking game where she was copying the sounds the therapist was making. The therapist let her do this for a minute, but then insisted that she work on blocks, so Sweets screamed and threw a tantrum. She did eventually work on the blocks though, but she also had a really hard time with it because they were lego-style blocks, and she can barely stack regular square blocks.
When the therapist came in, Sweets immediately started crying and was tearful for most of the session. The therapist said, "That's because she knows that I make her work!" In some ways, I understand that making her do these things even when she doesn't want to may be helpful for learning the skills. I feel a little uneasy about it, but then I wonder if she's right and that's what's necessary. But it just seems to me like it doesn't have to be a negative experience. She could have followed her lead and used the mimicking game for therapy purposes - at least that's what I would have done.
So, I really wonder, how child-led can I reasonably expect the therapist to be with her?
Example: Last time, she had it on her agenda to work on stacking with blocks. Sweets was not really interested in doing that and was trying to play a mimicking game where she was copying the sounds the therapist was making. The therapist let her do this for a minute, but then insisted that she work on blocks, so Sweets screamed and threw a tantrum. She did eventually work on the blocks though, but she also had a really hard time with it because they were lego-style blocks, and she can barely stack regular square blocks.
When the therapist came in, Sweets immediately started crying and was tearful for most of the session. The therapist said, "That's because she knows that I make her work!" In some ways, I understand that making her do these things even when she doesn't want to may be helpful for learning the skills. I feel a little uneasy about it, but then I wonder if she's right and that's what's necessary. But it just seems to me like it doesn't have to be a negative experience. She could have followed her lead and used the mimicking game for therapy purposes - at least that's what I would have done.
So, I really wonder, how child-led can I reasonably expect the therapist to be with her?
Subscribe to:
Posts (Atom)