Pediatric Therapist Recommendations VS Insurance Coverage

Insurance companies and other funding sources create arbitrary limits on the frequency (times per week) and duration (length per session) that they will cover and kids can get different amounts of services depending on which company they have.

More expensive plans typically have fewer restrictions, while cheaper plans or government funded plans place harsher restrictions on frequency and duration. This results in families with better insurance plans getting more services.

There is a lot of research supporting intensive therapy programs, especially at an early age, but many insurance companies do not fund this model. This results in therapists not recommending more intensive programs because they know it will not be approved OR families who can afford to pay out-of-pocket being the only ones to benefit from intensive models.

Therapists learn the different limits on services and begin to make their recommendations based off what they know the insurance companies will cover to avoid a fight.

We believe pediatric therapists and specialists should make recommendations about frequency and duration based on what their experience and clinical reasoning tells them will help the child and family the most and then insurance companies should fund services based on those recommendations. Access to longer or more frequent sessions should not be limited to families that have more expensive insurance plans or who can afford to pay beyond what their insurance will cover.

Families should be aware of the recommendations the therapist would make if there were no limits placed by the funding source. This way they could shop around if and when they were able to switch insurance plans. They could also use their therapist recommendation to appeal to their insurance company or seek a scholarship for services from their community.

If your child would benefit from a scholarship like this, please contact us at info@skyrockettherapy.org.