I had been having problems getting reimbursed for my special needs daughter’s out-of-network provider. I have been using out-of-network providers here and there and have never had a problem submitting claims. Well when she started PT, I kept getting denied. I was puzzled as all we had to do in the past was submit the superbill and we got reimbursed. I don’t even want to get into the headache about communicating with Anthem BCBS because I cannot speak directly to them as my union has a weird contract where I speak to the union and the union relays the message to me.

After paying full price for therapy for a year, we are introduced to SHEER. It’s a company that helps you get reimbursed….for a fee of that reimbursement. I am getting annoyed because we should be reimbursed 70% but aren’t and now I have to pay someone to get paid?! At this point, I am in the hole and any money is money. I get SHEER and it turns out my insurance needed care plans, progress notes, medical history, H&P from the Psychiatrist and Developmental Pediatrician, and prior authorization. I was pissed because that was on this gym to do. SHEER gets it cleared and I get reimbursed for June. I decide I can do this, just be on top of the gym.

I start doing this and try to get reimbursed for all the months I didn’t. It was a headache that is still in process but after my own investigation, I found out my gym was not coding “F84”, the diagnosis for Autism. They had been coding only diagnosises for lack of coordination and strength. I asked them to put it on the superbill and boom….no prior authorization, no care plan, just have to submit the superbill. The only thing that was different on it from last year’s was the “F84” code.

I’m angry. Angry that the only PT close to us is this place. Angry of the incompetency of the gym to properly bill. Angry that I can’t speak to my insurance company directly. And now Angry at SHEER. SHEER had all the documents that said my LO was autistic. They are supposed to be the experts at getting reimbursed. I had to tell them that the birthdays were wrong. Also, how could they not have noticed that the autism code was on it? My theory is they did notice. The additional two codes will come across to insurance as acute problems so that’s why they need to see progress via care plans and notes. Autism is a chronic condition so you are maintaining therapy hence not needing all the paperwork. I could never keep up with that and be forced to hire them. I only had a 6 month look back period to fight these reimbursements and it sucks all the money I lost due to this gym. I am trying my best for my child and wish there were better options.

Just needed a place to rant.