Question about occupational therapy, SPD, insurance, etc.

[Anonymous]

Hi. My 3.5 year-old son was recently referred by the occupational therapists that work with his preschool for a full OT evaluation and treatment to assess sensory processing, motor planning, self-regulation, and gross and fine motor development. They recommended Sensational Kids, Skills on the Hill, or Integrated Therapy Services, as well as Lynn Balzer-Martin for the evaluation, none of whom accept insurance. We now have Aetna Open Access (federal) but are expecting in March and can switch to another insurer then.

His issues seem relatively mild. He sometimes has a hard time with emotional self-regulation but socializes well with others and can keep up with most gross and fine motor activities. His pediatrician hasn't noticed anything, although she did write us a script for OT when I asked for it. We knew he had behavioral issues but had no idea there was anything sensory-related (although that's probably because we know so little about all this). We do, however, want him to be treated as soon as possible, especially if it'll help him adjust to a new sibling. I've spoken to Aetna, although they weren't very helpful in providing a list of pediatric OTs.

Questions:
1. Are there any pediatric OTs that accept Aetna?
2. Should we start immediately and just pay out of pocket for the evaluation ($650-750) and treatment sessions (approx. $130)?3
3. Should we wait 2 months when we switch over to another insurer?
4. Which insurance company should we switch to? Aetna only covers in-network providers, and I can't even tell from their web site which of their occupational therapists are pediatric occupational therapists.
5. Any other words of wisdom?

Thank you so much in advance for your advice. I'm relatively new to this forum but have been humbled and touched by many of the posts.

[Anonymous]

I am just starting this journey as well - sounds similar other than the ability to change providers. If you want to compare notes, please let me know. [e-mail]

[Anonymous]

We paid out of pocket for our SPD eval with Dr. Balzer-Martin and recommend it. Although SPD isn't turning out to be what triggers our child's behaviors, we started private weekly OT based on her recommendation, as it couldn't hurt. What I like about Dr. Balzer-Martin is that she ONLY does evals, so it isn't in her interest to find something as she doesn't provide the OT. She also will provide you with an itemized reciept with diagnostic codes that you can submit to your insurance for partial reimbursement.

We have BCBS federal standard, and I called my insurance and basically dared them to find someone in a 10 mile radius that is an OT specializing in preschoolers with SPD, Connections Therapy Center: http://thectcenter.com/. I was totally expecting to have to pay out of pocket. Turns out, they found someone in Lanham and we're really enjoying working with them, and it is only a $20 co-pay per session. Not sure who you talked to at your plan, but I pushed through the prompts until I found someone to help me with identifying providers. If Aetna isn't working for you and you can switch plans, do so. It might take you that long to get an appointment and go through the eval process anyway.

[Anonymous]

We have BCBS. We pay out of pocket, submit the invoices to BCBS and then get reimbursed.

[Anonymous]

Thanks! 13:54, do you have BCBS Standard or Basic? And how much do you get reimbursed?

[Anonymous]

Anonymous wrote:We have BCBS. We pay out of pocket, submit the invoices to BCBS and then get reimbursed.

This. I have found no one in the area who accepts insurance for SPD. We pay OOP and submit. We get about 50% of the allowable set by our plan back for each unit of service.

[Anonymous]

My son has SPD and goes to Exceptional Children's Center in Springfield. They performed the evaluation and he goes there twice a week for OT. They've been wonderful and we love his therapists - he's made significant improvement in the last 9 months. Our insurance covered everything and we pay a co-pay for each OT visit.

[Anonymous]

I don't know of any OTs who accept insurance. We do the reimbursement thing too, but I can't remember what the rate is. Most plans have a cap on number of visits per year.

We did Sensational Kids for several years and had a good experience.

[Anonymous]

13:54 here- not federal. We have plain old ppo.

[Anonymous]

Childrens and GT accept insurance and so does KKI.

[Anonymous]

Pp, new poster here. Any recommended OTs at Children's? Thanks!

Crazy that we pay so much for insurance and the it is so hard to use it.

[Anonymous]

As to CNMC OT, unfortunately no.

Agreed. I pay more than 1K a month out of pocket and have a 5K in network deductible and a 10K out of network one (non combinable too, so really 15K deductible if both types used). I have a 20 session limit too. Just a small fraction of the OT that will be needed in our case - let alone other therapy and assessments etc etc

[Anonymous]

Pediatric development center accepts BCBS.

[Anonymous]

OTs out in the burbs accept insurance. I think closer in there is less competition. We have no dx and our insurance (cigna, crappy) pays for 60 visits a year with a $30 copay per visit.

We go to Childrens Therapy Center in Sterling. The evaluation was free. Fleming Therapy also accepts insurance and will do a free evaluation. Good luck-

[Anonymous]

Bump. Looking for OT, ideally in DC, that takes CareFirst. Am I dreaming? Any help appreciated.