Insurance form

Sorting Out Insurance: PPO’s vs. HMO’s

Insurance is a wonderful thing to have as it helps us get the medical attention we need, but trying to understand the ins and outs of Insurance can be a bit frustrating. Below are some basic facts and terminology as well as questions to ask your insurance provider when trying to figure out if a medical procedure or therapy is covered.

What is the difference between a PPO and an HMO?

–A PPO allows the individual or family covered under the plan to go anywhere they want for treatment/services.

–An HMO has a list of providers they are contracted with for services, so you must choose from the list if you want services to be paid for by the insurance.

I have an HMO, what is the next step once a specialist or facility is found?

Once you select a specialist or a facility, you will need a “Referral” from your Primary Care Physician (PCP).  This is created by your PCP office and sent to the HMO for approval and authorization.

–When you contact your PCP, ask for a “referral coordinator”…this person will be the most helpful.

–If there is not a “referral coordinator” on staff, make sure to tell the nurse or receptionist you need a “Referral for the HMO”.

My PCP gave me a Referral, how do I know if it is correct?

–This is where things can get tricky!  Sometimes a PCP will write a Referral for services, but it is not approved by the HMO.  To tell if it is correct, look for an “authorization #” and an “approval to and from date”.  There may also be a specific number of visits that are approved.

  • Here are some basic terms and what they mean:

1) Deductible (DED):  This is what you must pay or “meet” before the insurance will start to pay their portion.  Sometimes there is an Individual DED and sometimes a Family DED.  Ask the insurance if you need to meet one or both of them before they will pay for services.

2) 80/20, 90/10, etc:  This refers to the percentages that the insurance will pay and the responsible party will pay.  The first number is the insurance’s part!

3) Copays:  This is what the responsible party pays for each visit.

4) Pre-authorization:  This may be required prior to starting services.  A reference or case number is usually given to track the review process by the insurance company.  You may also need authorization after a specific number of visits to continue therapy.

5) Visit limit (max # of visits):  These are usually seen when therapy is involved.  There are some policies that have no limit, so you can be seen as many times as needed, as long as there is a medical necessity.  Also, just because you may be given a visit number, it does not mean you are guaranteed all of them. The insurance may review your case and determine the therapy is not medically necessary anymore.

a) Hard Max:  This is the number of visits allowed by the insurance company during the policy year.  Unfortunately, there is no way to get more visits if you run out.

b) Soft Max:  If you should need more than the allotted amount, you are able to have the insurance review the case to see if more visits can be given.


What a Diagnosis of Cerebral Palsy Means for Your Child

For new parents whose children are diagnosed with Cerebral Palsy (CP) and parents whose children with CP are nearing school age, understanding the diagnosis, prognosis, and the interventions available is often their top priority.  Being a first-time parent is challenging enough, and for many parents looking for answers, a medical diagnosis provided by a doctor often leads to more questions.

What having Cerebral Palsy means for your child:

Cerebral Palsy is a broad term used to describe a neurological condition that impacts physical functioning in children. The presentation of CP in individuals affected is highly varied in terms of severity, symptoms, and deviation from typical development.  The condition itself is explained by a brain lesion that occurred in utero or around the time of birth (such as an in-utero stroke, brief oxygen deprivation before birth, or a birth trauma to the young brain).   The neuromuscular system is affected, leading to motor impairments that hinder a child’s voluntary muscle control. Put simply, a child’s ability to control his trunk and move his body parts become limited.

Muscles and our brain’s ability to control them are a huge part of our physical function, from our vision and speech, to our sense of balance. This impaired control and coordination of voluntary muscles affects children in a variety of ways, depending on the location, timing, and severity of the brain lesion.  Much like a brain injury can affect a mature individual’s ability to control his limbs, a lesion in the immature brain often leads to decreased postural control and delayed physical development.  The lack of motor control is not always, but is often correlated with cognitive delays and learning disabilities, speech delays, visual or auditory impairments, and seizure disorders.

There are many misconceptions in the general community about children with CP.  Many people think CP is associated with mental delays and poor independent functioning. This is simply not the case for everyone with cerebral palsy.  Cerebral Palsy is often classified in different ways based on the movement disorder (stiffness, rigidity, low tone, uncontrollable movement, etc) observed. No matter the diagnosis or presentation, a team of healthcare professionals is absolutely essential to improve the lives of children and families affected with cerebral palsy.  It is important to begin a treatment program as early as possible to ensure a child develops to his or her full potential.  Sometimes, a child with CP may need surgery, orthotics, assistive technology, early intervention therapy, or medications, to improve their function and independence.

The role of the physical therapist:

One of the first steps to take after receiving a diagnosis of cerebral palsy is to discuss with your pediatrician and your child’s medical team about the interventions currently available and the interventions needed long-term. Often times, physical therapy becomes an indispensable part of a child’s medical care. Physical therapists will develop a plan of care based on the child’s abilities.

Our goal as physical therapists is to improve a child’s independence by doing the following:

  • Teaching him to move and play while protecting his joints from abnormal movements/postures
  •  Helping him strengthen muscles that are weak, keep stiff joints mobile, and stretch out muscles that are tight
  •  Fitting him for special equipment to help him stand, walk, and participate in school and life activities as needed
  •  Working with his family and caregivers on adaptive techniques and changes to their home or school environment, to allow him to interact with other children and participate in daily tasks
  •  Addressing his limitations and movement disorders by improving his posture, walking mechanics, endurance, and pain
  •  Accommodating for his changing needs as he matures and as new challenges arise, and
  •  Providing the child and his family emotional support, healthcare references, and professional insight to help him transition into adulthood.

Every child with cerebral palsy develops differently. The importance of early therapy is to help a child live up to his full potential with this neurological condition.

Reference: Olney SJ, Wright MJ. Cerebral palsy. In: Campbell SK, eds 3. Physical Therapy for Children. Philadelphia, Pa: WB Saunders Co, 2004 :625-664.

Can Technology Replace Therapy?

With the changes in science and technology, there has been major changes and adaptations with pediatric therapy.  There are many applications available that provide therapists and children with technological support.  These applications can be found on a variety of sources such as, but not limited to, the iPad, Kinect, Wii, Kindle, etc.  There has been much support for such technology as evident by a New York Times article on on physical therapists using Wii Golf to help enhance the benefits of the therapy.

Now the question that should be asked is why bother with therapy when a parent can spend a lot less money and time by buying applications and video games?

The applications must be considered only one aspect of developmental therapy. They are tools that help with the therapy; however, by no means supplement the benefits of the therapy itself.  Developmental therapists have specific training on developmental therapy and how to help children develop to their potential at the quickest and most efficient manner possible.

So although there have been major breakthroughs with technology and software; I will never foresee a time in which the technology will replace the therapist.

My Child Is Tongue Tied: What Does This Mean?

What is Tongue Tie (Ankyloglossia)?

Ankyloglossia, or more commonly referred to as Tongue Tie, occurs when the lingual frenulum (the thin band of tissue that connects the bottom of the tongue to the mouth) is too short and tight. Reports on the prevalence of tongue tie in newborns is conflicting, though current research indicates that this occurs in approximately 1-4% of newborns. Tongue tie may interfere with breastfeeding, and your newborn my present with significant challenges latching, remaining on the nipple when feeding, and fussiness during feeds. Nursing mothers may also experience significant pain when breastfeeding, even after repositioning.  You may notice that your baby has difficulty sticking their tongue out and the tongue shape may resemble a heart, as observed by a “V” indentation in the tip.  If tongue movement is restricted, tongue elevation, lateralization, and protrusion may be negatively impacted.  Tongue tie is not commonly identified at birth, however if you do have concerns, you should speak with a lactation consultant, speech-language pathologist, or your pediatrician.

What are the effects of my baby having Ankyloglossia?

However, it is presumed that long-term effects are not commonly seen in children with tongue tie. As an infant continues to grow, the frenulum in turn stretches and allows for increased tongue movement.  In rare cases, speech development may be negatively impacted by the severity of the tongue tie, as the tongue is unable to coordinate specific movements to produce targeted sounds. In cases where tongue range-of- motion are profoundly impacted by the tongue tie, the child may undergo a frenotomy or  frenulectomy in which the lingual frenulum is clipped to increase tongue movement.  There is continued debate about whether it is beneficial to “clip or not to clip”, as many healthcare professionals disagree on the effectiveness and supposed outcomes of the surgery. Each case is unique however, therefore an extensive oral-motor and feeding evaluation should be completed in order to assess the severity of the tongue tie, in order to determine the best plan of care for the child.

Questions to Ask Your Pediatrician When You Suspect a Developmental Delay

Pediatricians oftentimes only have fifteen to twenty minutes with a child and family during a wellness visit.  Most of that time would bequestions to ask your pediatrician when you expect a developmental delay used to ensure the medical health of the child.  It is imperative that time also be spent on ascertaining information regarding the social, emotional, and behavioral development of the child.  I always recommend that parents bring with them a list of questions that they have regarding their child’s development.

Questions to Ask Your Pediatrician About Your Child’s Development:

  • Ask the doctor questions about his or her language development.   Is the child meeting necessary developmental milestones with regard to his or her speech and language?  Are there any concerns that might be addressed through speech and language therapy? Read more

How Can a Neuropsychological Evaluation Help My Child?

A neuropsychological evaluation can help a child in multiple ways.  The focus of the evaluation is to provide information for parents about why a child is struggling with regards to his or her academic achievement, social engagement, and/or emotional regulation.  Parents will bring their children in for a neuropsychological evaluation when they have concerns about their performance in any of the above domains.

What is the goal of a neuropsychological evaluation?

The goal of the evaluation is to provide diagnostic clarification based upon a set of symptoms that the child exhibits.  This information is attained through the following ways:

  • Parental interview
  • Parental and teacher report
  • Behavioral observation Read more

How to Talk to Your Kids about Weight and Healthy Eating

We all want our kids to be the healthiest they can be. In recent years, we are seeing serious health problems presenting in young kids and adolescents. An unhealthy diet and lifestyle affects kids’ quality of life, and this is often what hurts them most. Kids with weight issues may get teased at school or start to withdraw from activities that were once a big part of their life, such as sports. This can make the weight issues even worse for them.

If you find yourself in a position of having to talk to your child about his or her weight, consider some of the points below. These tips apply to both overweight and underweight issues.

Explain BMI and the importance of being in a healthy range.

BMI stands for body mass index. Your child’s pediatrician should be measuring your child at well checkups and plotting their BMI on a growth chart. You can explain BMI to kids by saying, “BMI is a measurement of how much weight is on your body for how tall you are.” Read more

Speech Therapy or a Prosthetic? What is Appropriate for Hypernasal Speech?

When dealing with hypernasal speech, the cause is typically with the velum (i.e., the soft tissue on the top of the mouth located in the back of the oral cavity). The velum may be WEAK or it may be INSUFFICIENT. Knowing the difference between these two scenarios may indicate whether a trial speech therapy period is warranted or if a prosthetic device may be more appropriate.

Treatment for a weak velum:

For a WEAK velum, trial speech therapy is suggested. There are several techniques and feedback tools that a speech therapist can use to encourage oral resonance by increasing the strength and coordination of the velopharyngeal area (i.e., the soft tissue velum and the muscles in the back of the throat) to close appropriately for speech. Specific sound misarticulations can also be coached into correct production.

Treatment for an insufficient velum:

For an INSUFFICIENT velum, however, speech therapy will most likely not aid in increasing the intelligibility of speech as the muscle and/or structure of that velopharyngeal area is not a sufficient size to maintain closure. In this scenario, surgery or a prosthetic device is the most likely course of action. The major prostheses available are speech bulbs and palatal lifts. A speech bulb is a piece that fits to partially close off the space between the velum and the pharyngeal wall to assist an insufficient closing. A palatal lift is a device that fits along the roof of the mouth to close off fistulas (i.e., very small holes in the roof of the mouth) and lift the soft palate up to decrease the effort necessary to close off the nasal cavity. A craniofacial specialist can assist you with determining appropriate options.

Process Reduction Therapy:

Process Reduction Therapy is a combination of the above situations. There is research indicating that using a prosthetic and gradually reducing the size may encourage an increased ability for the nasal cavity to close off.

Speech therapy is an excellent option for many children with hypernasal speech. Determining the cause of the hypernasal speech will provide the appropriate path for the child and help guide treatment. Contact a licensed speech pathologist with questions or concerns.

The Proper Way to Wear a Backpack

Have you ever picked up your child’s backpack and thought to yourself, “That cannot be good for her posture or back muscles!” or “How does she lift this?”  Carrying a heavy backpack can put strain on your child’s back and shoulder muscles, which can lead to bad posture and muscle aches.  A child carries her backpack for a significant amount of time during the school year, and wearing it inappropriately can impact her posture and overall health.  Read on for tips for properly wearing a backpack.

Tips for properly wearing a backpack:

  • A loaded backpack should NEVER weigh more than 10% of your child’s total body weight (AOTA, 2013).  For example, if your child weighs 60 pounds, her backpack should only weigh 6 pounds.
  • Make sure your child positions items in the backpack with heaviest items closest to the body and lightest items toward the outside of the pack.
  • Discuss organizational strategies for backpacks with your child; make sure ONLY necessary school items are in the backpack.
  • Your child’s backpack should have padded shoulder straps to prevent strain or impingement placed on your child’s shoulder muscles or nerves.
  • Make sure the backpack rests close to the child’s body and does not hang lower than her lower back.
  • If a waist belt is provided on the backpack, make sure your child wears it to help distribute the weight of the backpack more evenly on both sides of the body. Read more

How to Use Theraputty to Develop Hand Strength

You may have seen your child’s occupational therapist (OT) using a tool that looks like a chunk of clay during your child’s therapy sessions and wondered, “What is that?!” This tool, called theraputty, is a resistant play dough that works on strengthening the small muscles of the hands and fingers. Theraputty can be used in a variety of ways to improve hand strength, while also being highly motivating for children.

Ways to Use Theraputty to Develop Hand Strength:

  • Hide marbles or buttons in the putty, and have your child go on a treasure hunt to find the items.
  • After your child finds the objects in the putty, have him hide them in the putty and give the putty to a sibling to go on a treasure hunt.
  • Hide coins in the putty. What your child finds, he can keep! Read more