IEPs and Insurance

Dealing with people who don’t want to spend money on your child (even though they are legally obligated to do so) can be one of the most frustrating aspects of dealing with atresia and microtia. But knowing what you will face in advance of asking for it, and knowing what your rights are will make the process that much smoother.

INSURANCE

Here are some hints for dealing with insurance appeals

1. Insurance companies regularly outright deny coverage for auricular reconstruction surgery, categorizing it as “cosmetic surgery”, or they will agree to cover it but only if you use their inexperienced in-network surgeon. Don’t fall into this trap, they are obligated to provide you with a competent surgeon, and if they can’t provide one in-network, they have to go out of network at in network rates (to you).

2. Document, document, document. If you don’t have it in writing from an insurance company, it did not happen. If you have a phone call with them with a favourable answer, send that person a letter saying “this is my understanding of our phone call – you agreed that BAHA surgery was covered. If this is not the case, please write me within 10 days”

3. Always send everything to insurance companies with delivery confirmation.

4. Expect this to take a while. Insurance companies will drag out the process as long as possible. If 5 % of the people go away at every stage (phone call, written request, first appeal, second appeal, IMR) that’s 30 % of the people who need this surgery (at a cost of 30-60K) each who they don’t have to pay for, and that’s money in THEIR pockets.

5. Find out who your local state and federal representatives are as well as the name of your insurance commissioner. CC them on all major correspondence with the company. If your local newspaper, radio, or TV has a consumer advocate line, try to get them involved. Insurance companies hate nothing more than bad publicity, and refusing to perform surgery on a child born without an ear makes them look like the chumps they frequently are.

6. When asking for a particular surgeon, never say that surgeon is the best person for the job. Insurance companies are not obligated to provide you with the best doctor, only a competent doctor. Simply use statistics to say why the surgeon they are suggesting is not competent to do the job. (i.e. Doctor X has a 16 % failure rate, while Dr. Y has a 2 % failure rate)

7. Accept at face value that insurance companies don’t care about your child, they care about money. So make the letter about how doing what you want will save them money. Some examples include

a. I want the medpor implant, which can’t be done by your in network surgeons and my child will only have to be in the hospital two times instead of 4.
b. The chance of failure with Dr. Z is so high, that it is quite possible your child will require secondary auricular reconstruction requiring travel to California or Japan at the insurance companies cost.
c. You are requesting a BAHA (at a cost of approximately $14,000) in lieu of a canalplasty at a cost of $30,000 with a X % failure rate

If you need help with an insurance appeal, contact an Atresia Microtia Foundation advocate by e-mail at advocate@atresiamicrotia.org

IEP / IDEA/ 504s

These are all different methods of ensuring your child gets an appropriate public education in the United States.

IDEA

IEP

IEP stands for Individualized Eductional Plan. It is a written contract between you and the school that identifies the accommodations, equipment, and special services your child will require because of their hearing loss in order to receive a fair appropriate public education.

Because every IEP is different, the contents can range anywhere from placing your child in a special program at a special school, to providing them with an FM System, to acoustic modifications to classrooms and special teacher training, to speech therapy and tutoring.

504s

29 U.S.C. § 794 (Section 504) is a federal law designed to protect the rights of individuals with disabilities in programs and activities that receive federal funds from the U.S. Department of Education (ED). Section 504 provides: "No otherwise qualified individual with a disability in the United States . . . shall solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance . . . ."

Any child with both aural atresia and microtia qualifies for 504 protection. The language in question is:

To be protected under Section 504, a student must be determined to: 1) have a physical or mental impairment that substantially limits one or more major life activities; 2) have a record of such an impairment, or 3) be regarded as having such an impairment.

Therefore, all you need to qualify for a 504 is an audiogram to prove the child’s hearing loss.

See http://www.ed.gov/about/offices/list/ocr/504faq.html for more details.