Health care and wellness ~ 2017

Health care and wellness ~ 2017

Therapeutic Dimensions™ offers therapy services in Phases
to allow families, care providers and children to learn and experience a new expression of their fullest potential. Each 3 month Phase has 12 and 6 week options to ensure depth with balance of your family’s rhythms within your community.

We’re nearing the halfway mark of our Phase l program and gracefully approaching our Phase ll cycle with new strength.

This is the time for you to plan for the coming year and to learn about your health care benefit options during “open enrollment” season. Make sure you check your employer’s or your own insurance plan’s programs to learn how to shop for a package that is affordable and fits your family’s needs and supports your personal wellness priorities and commitments.

When you choose an out of network specialist in your area (close to your home) who has advanced credentials and works holistically (integrating child, family and community) be sure to communicate your priorities as you’re selecting your insurance plan and working with your primary care physician.

A few of the key advanced credentials I’ve earned for your consideration are certifications in Simplicity Parenting and Collaborative Counseling, Spacial Dynamics, Sensory Integration and Pediatric OT (through intensive peer review and evidence based research). Please prepare and plan ahead for your healthcare and wellness (investigational practices) to guarantee your own results. By advocating and caring for your healing you’ll be receiving the care you’re sharing in daily life.

If you or your child’s teacher would like to request a home or classroom observation and discuss a plan of care for Phase ll (starting in January 2017) now is the best time to set up a phone consultation to discuss your needs. Current clients will find the steps uploaded to their client portal for planning ahead and preparing for this coming year’s Phases <3 Mary

{ 1 comment… add one }

  • Mary Blake October 16, 2016, 5:54 pm

    Dear Clients and Care Providers, October 16, 2017

    Most health care plans offer coverage for a portion of Therapeutic Dimensions services. We think it’s important to know what services are covered and how to advocate for coverage.

    Managed care plans provide you an opportunity to chose a policy and a provider to fit with your needs. We want you to be aware that “approved coverage” may not always mean that you will be reimbursed. Reimbursement can also be recouped by insurance companies after treatment is provided if the required documentation or procedures are found incompatible.

    Therapeutic Dimensions, PA provides (re) habilitative, remedial and wellness services using therapeutic exercise and sensory enhancements within a progressive treatment program. We offer consultation and educational training for care providers to support clients to learn and to follow through with daily activities to improve perceptual abilities, motor coordination, and skills for functional community centered care to safely participate in activities of daily living, play and socially inclusive community recreation.

    We often receive questions about medical and educational services for treatment of Sensory Integration and Processing Disorders. We hope the following information will help inform you so you are able to advocate and receive appropriate services. There are many ways to receive reimbursement for OT as long as you know how to plan ahead for your child and family’s needs. We want to assist you and recommend that you start now to prepare for your needs.

    Access to treatment with sensory supports is necessary and is considered a component within a comprehensive therapeutic OT intervention plan. However, these type of specialized services are considered investigational and may not be fully covered by your insurance plan.

    Therapeutic Dimensions provides services for sensory processing differences requiring specialized training and advanced clinical skills for observation and treatment using standardized tools and equipment in therapeutically designed spaces to ensure evidence based results. In the medical field, sensory intervention tools and methods cannot yet be designated specifically for sensory integration therapy due to current lack of research and understanding of the wide variety of behaviors within a large spectrum of severity and diagnosis in working with children and families. Therapeutic Dimension’s observations of presenting characteristics of sensory related behaviors and therapeutic goals are carefully documented to measure change and functional outcomes. In this way, therapeutic enhancements are made available as part of natural environments to support individual client preferences and care provider’s goals. Therapeutic Dimensions regards sensory tools and methods as a means to provide age appropriate, wellness and developmental activities, complementary to treatment of a specific medical diagnosis or an impediment that prevents access or impacts one’s functions during daily life activities. All care providers are trained to observe, describe and witness physical changes by applying specialized techniques offered uniquely by Therapeutic Dimensions for medical or educational necessity considerations.

    Insurance companies offer different types of coverage and will not cover specialized services unless there is prior authorization for medical necessity. We do not provide diagnosis for our clients. You must contact your physician to discuss a referral and call your insurance provider to know if a specific diagnosis is covered for your OT referral/prescription from your PCP. It’s important to be specific about how many sessions are needed and the dates for your referral.

    Therapeutic Dimensions, PA provides the following procedures based on your medical referral with a diagnosis and treatment codes necessary for insurance reimbursement. All information is available to you on your invoice to view, download and print to send to your insurance company. Early intervention medical diagnosis may be covered up to 21 years old.

    97110 Therapeutic Exercises – active performance on body areas or parts with steps/instructions, demonstration and practice/repetition

    97535 Self Care – home management training, prevention and awareness for family and care providers

    97530 Therapeutic Activities – progressive dynamic movement for functional performance (bending, lifting, carrying, catching, reaching, grasping, opening)

    We are committed to evidence based practice and offer the following assessments with documentation as agreed upon before starting services, in addition to our therapy sessions.

    Evaluation/Assessment and re evaluation of progress using objective and subjective observational measures to determine conditions and a treatment plan towards goals.

    Documentation of progress at regular intervals to reduce limitation, improve function and monitor programs for motor, perceptual & activities of daily living.

    We provide treatment notes after each session and all clients are asked to record observations by keeping a journal/diary of home practices. We ask that you provide TD access to behavioral specialists or other consultants for any program recommendations.

    It is important to understand your benefits ahead of time to know if the assessment is covered under your plan. You are responsible for prepayment of non covered services
    and your copayment and deductibles will be due after each of your sessions. Our client agreement states you will pay for any uncovered services within 30 days of your session.
    Upon request, we will submit a CMS 1500 on your behalf to your insurance company and
    you will receive payment if your insurance plan covers out of network or specialized services.

    Each insurance plan has different rates for in network and out of network service providers. The best way to appeal for out of network services paid at in network rates is to ask your primary care physician in network to determine a medical necessity for OT outside of the network through a GAP extension or insurance appeals processes with a letter from your MD.

    You can discuss a medical necessity plan of care from your PCP in network “to relieve related social and behavioral symptoms of dyspraxia, motor incoordination, lack of endurance and/or balance issues as well as fine motor or visual motor delays impacting physical participation or independence in daily functions to prevent injury” You might also be considered for a pre existing condition with coverage approved through a former insurance if you can provide rationale supporting an extra burden any change in service providers could place on you and your family due to these changes. Be sure to prepare ahead of time for 3 – 6 month appeals.

    To prepare ahead of time and avoid appeals, your place of employment or benefits administrator will help you understand how to access your insurance benefits, HSF or HSA.
    If you would like Therapeutic Dimensions to have a conversation on your behalf with your in network MD (PCP) insurance provider feel free to set up an appointment. We will be able to speak on your behalf if we have received a signed release and a signed client agreement.

    Therapeutic Dimensions primarily receives referrals for pediatric clients and we use the following reference information to help define our “specialized therapy practices”.

    The American Academy of Pediatrics recommends “unlimited visits for children
    (0 – 18 years) for rehabilitation due to a neurophysiological and structural deviations/abnormality associated with clinical findings and a progressive response and/or partial progress to treatment and continued home educational programming” and specifies insignificant changes in treatment frequency include “decrease in frequency and duration due to illness, modifications of short-term goals to adjust for improvements, deletions of achieved goals, or specific interventions, levels of assistance, range of motion, strength measures, changes to caregiver instructions”

    Session time includes 15 minutes for transitions with caregiver instructions at the beginning and ending of sessions. Children frequently experiences disorientation due to delays in processing at transitions. Following an initial 15-minute orientation period of clinical observation the child is guided and instructed to begin creating a visual spatial body map with sequences for communication during therapy activities and exercises. Therapeutic processing time for each exercise varies depending on individual needs and responses may vary with children for up to 60 – 90 minutes to achieve functional performance measures.

    Therapeutic Dimensions is typically reimbursed by insurance for 2 hours one time
    per week versus one hour two times’s per week given the above rationale for length, duration and frequency of visits. Insurance typically allows 15 minutes of patient preparation at the beginning of sessions and 15 minutes of note taking with a patient present in recovery.

    Here are a few examples of basic coverage requirements for most insurance plans ~

    “An evaluation is necessary at the start of services to establish a baseline and plan of care including a discharge plan with measured functional family goals” Services provided within “usual and customary” guidelines occur during the course of 6 week and 12 week treatment plans once per week with progress updates to determine the need for further services.

    “OT/PT or OT/OT visits on the same day may be denied as duplicate services. OT or PT visits rendered by two different therapists on different days may be covered as two separate services and must be billed as two different codes two with different treatment plans requiring two separate MD referrals to evaluate the medical necessity for both.”

    “A self pay client agreement must be entered into prior to initiating services when members chose to pay for services out of pocket beyond coverage limitations for visits.” If your plan does not cover wellness or alternative/investigational services, clients may choose to pay for preventative care at their own expense. Clients may obtain an extension beyond coverage limitations for visits through patient appeal for required and/or all specialized circumstances.

    Guidelines written by the American Occupational Therapy Association and Department of Education for best practice in delivery of Medical & Educational Occupational Therapy services are available. If you would like to receive this information please let us know. We also have sample letters written by a Parent, a School Occupational Therapist, and a Physician to help you clearly articulate the rationale for pediatric services. We can also give you access to supportive research and websites to provides further resources. We would be happy to send you our preferred links, copies of recent articles and/or letters to keep you informed.

    In the Upper Valley, there are several hospital based OT’s and private practices who serve adults and also pediatric clients in an outpatient model not specially designed for working with children and families. Most of our clients who request coverage for Therapeutic Dimensions services at in network rates provide the rationale that there are no specialized pediatric trained Occupational Therapists with advanced credentials serving the needs of families and children within a 30 mile radius. An MD referral (or letter of appeal) must state a medical need and a diagnosis to determine and support rationale for specialized OT services.

    Prior authorization typically allows for up to 8 units per day (15 minutes per unit) as
    a maximum allowance for any treatment code (considered as one session) per week.
    Some plans require a medical review after a certain number of sessions billed for one diagnosis. Services requested beyond the “usual and customary” of your plan benefits must be requested repeatedly by your MD through a referral and re evaluation determining need.

    In summary, our services may be covered by most Insurance companies as long as you discuss a referral with your MD to request “specialized OT services” from a qualified pediatric “out of network provider” at in network coverage rates. Patient appeals may take time so please let us know if you need correspondence from us on your behalf as soon as possible after you’ve received a denial. It’s best to plan ahead to avoid an appeals process by working with your in network MD. It’s very important for you to keep track of Therapeutic Dimensions invoices sent to your portal on VCita so you can apply your copay or deductible on the correct date when your insurance check arrives so each invoice will match with “Paid in Full” on your portal. If you are not paid by insurance within 30 days it is your responsibility to pay for all non covered services until you have obtained an appropriate referral for this purpose.

    If a denial is received for any reason, you are liable for the unpaid portion and Therapeutic DImensions will apply your deposit or prepayment. If you obtain a new referral you can request updated invoices and resubmit corrected claim forms. These forms are completed by the policyholder and are available from your insurance plan website or benefits coordinators.

    As a regular client with Therapeutic Dimensions, we offer free 15 minute phone consultations for your convenience. We encourage you to schedule times with us on our website or if you email us we’ll send you an appointment to speak with us at your preferred time.

    We always welcome your questions and your feedback as an ongoing opportunity to learn what is most important to you. We hope this information is helpful to you and we’ll share our work with others while continuing to serve you, your child and family’s needs for many years!

    Sincerely yours,

    Mary Blake, Director

    Therapeutic Dimensions, PA

Leave a Comment