Fall 2021 – Therapy Services: What’s Best and How to Avoid Denials
Many of our children’s therapy services were disrupted over the past year. Perhaps virtual school made therapy impossible, or you paused on taking your child into a clinic for therapy. Now might be a good time to return to those in-person therapy visits. But first, think about the goals for your child’s therapy services:
- Which skills should school focus on?
- What are your priorities for community therapy?
- What kind of therapy will have the biggest impact?
Therapy at School
If your child qualifies for special education, he or she likely will receive therapy services during the school day. Most often these include physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services. Your child’s IEP team, including you as a central team member, will decide:
- Which therapy services your child will receive.
- The setting, like the classroom or playground.
- The number of sessions per week.
- The length of each session.
You may be asked to sign an authorization for the school to bill Medicaid for therapy services. Signing this form does not mean you are financially responsible or that your child can’t also receive Medicaid coverage for community-based therapy. It only means that your school can get reimbursed for the therapy services it provides.
Children can receive therapy services at home, at a clinic, a hospital or in other community settings. These services likely start with a visit to your primary care provider who will talk with you about your concerns, and areas that therapy can improve.
To find therapist, talk with your clinic, contact your Regional Center for Children and Youth with Special Health Care Needs, or visit the Well Badger Resource Center. Your child’s school and other families will have good suggestions about finding community-based therapists in your area.
Tip for Families
To help avoid insurance denials make sure that your child’s school-based and community-based therapies have different goals. Medicaid may deny payment for community-based therapy if it’s a duplication of services, meaning the goals of school and community-based therapies are not distinctly different. To learn more, read our Therapy Services Fact Sheet.
A Therapy Plan
Any therapy services that your child receives, either at school or in the community, should be guided by a well thought out and coordinated therapy plan. As your child’s best advocate, your input is necessary as school staff and other providers decide which therapies are best to help gain new skills. Your understanding of your child’s needs will direct therapy goals.
Covering the Cost and Avoiding Denials
While school is responsible for covering the cost of school-based therapy, you are responsible for making sure your insurance plan, HMO or your child’s ForwardHealth card will pay for community-based therapy services.
Depending on your plan, you may also need a prescription from your child’s doctor. Additionally, your child’s therapist will need to submit a prior authorization (PA) request. The PA lets your insurance plan or Medicaid know that the service being called for, including community-based therapy, is medically necessary for your child.
Recently DHS simplified the Medicaid PA process. “This simplification is intended to increase children’s access to therapy services in the community and to reduce the documentation that providers are required to submit to ForwardHealth.”
What is Medical Necessity?
For Medicaid to approve coverage for therapy services, the provider must show that it is medically necessary. DHS states, “Medicaid may deny payment if a service fails to meet Medicaid medical necessity requirements as defined under HFS 101.03(96m), Wis. Admin. Code.” To learn more, see Family Voices fact sheet Insurance Prior Authorization .
DHS’s full Definition of Medical Necessity.
What About Children’s Long-Term Supports?
If your child is enrolled in one of the children’s long-term support programs, CLTS and CCOP, their plan may be able to cover the cost of therapies not covered by their ForwardHealth card. Aquatic therapy and hippotherapy are example of therapies that might be covered. You’ll need to work with your service coordinator to develop outcomes that show these therapies are needed to meet your child’s goals. See our Creating Outcomes Fact Sheet to learn more.
Tip for Families
Find a new balance. Before COVID, if you spent endless hours driving your child to therapy sessions, think of this time with fewer appointments as a gift. Remember that it’s also important for your child to just be a kid. Spending time outside with siblings or neighborhood friends is also necessary for your child’s development.
What if Medicaid Denies My Child’s Community-based Therapy?
Your child’s community therapist submitted the prior authorization request to Wisconsin Medicaid…. But after submitting the PA repeatedly, it was denied.
There is a better option before you give up or pay out-of-pocket. Families can, and should, appeal the Medicaid denial and request a fair hearing. You don’t need an attorney and all hearings are currently being held by phone, so you don’t need to leave home to appeal a denial. But, you will need to act quicklyꟷYou only have 45 days after receiving the denial letter from Medicaid to make your request. Learn more with our fact sheet on Appealing a Medicaid Denial and the Advocate’s Guide to Fair Hearings.
The Wisconsin Department of Public Instruction has information for families and professionals on the therapies that your child may get at school.