Monday, January 12, 2009

It's all about the diagnosis

I work for an agency that processes the medical portion of Social Security claims. My claimant get caught up on (among many things) their diagnosis. We are a functional program. Your diagnosis is good and all but it is how you are functioning despite your impairment that pretty much determines whether or not we are going to allow or deny you.

I talk to claimants all the time and they say "but I have this" or "but I have that". They don't understand why my questions on what they are able to do during the day matter so much. I didn't understand why their emphasis on their diagnosis mattered so much. Then I had Lauren.

She was first diagnosed with a developmental delay. This can be one of the worst diangosises to have from an insurance standpoint. Many insurances won't pay for therapies with kids with this diagnosis. The crazy thing is that kids with developmental delays get better a lot faster with therapy.

Therapies such as speech, occupational, and physical helps kids function in an age appropriate manner. It helps kids be who they were meant to be. It changes kids lives. Many kids with developmental delays will get better on their own without therapy, eventually. However, it is a much harder road and a much longer road. Not getting therapy can create worse problems for other kids. This will necessitate more therapy and probably for a longer time than if their developmental delay would have been treated earlier. This will eventually cost the insurance company even more.

Other programs, such as MRDD, are diagnosis driven. Lauren was eligible for services through MRDD until she hit age 6. The reason for this is because she was diagnosed with a global developmental delay. At age 6, the criteria for MRDD changes and the impairments need to be life-long. Developmental delays don't cut it. However, Lauren's neurologist changed her diagnosis to Pervasive Developmental Delay, Not Otherwise Specif iced (PDD, NOS). Her function has not changed at all but her diagnosis has and we expect that she will be eligible for services until she is at least 16.

I got an Explanation of Benefits (EOB) from my insurance company today. Lauren's neurology visits have been denied. I called to find out why and the reason is that it was coded in as a learning disability and our insurance does not provide services for that. I now have to call and talk to someone in billing and figure out how to get these services recoded and then re billed.

It will happen because her neurologist knows that she definitely needs his services. Her pediatrician won't do anything with her medication because she is now beyond their scope of expertise. But it's time consuming and it's something I have to remember to do while I'm at work (when I should be helping my state-ians with disabilities). It's sad that she needs the services and this is just an extra headaches. But remember it's all about the diagnosis.

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