SENECA, Pa. — Kim Plyler, Administrative Assistant of Next Step Therapy, submitted the following article: “Understanding Medically Managed Insurance Plans:”

Any Insurance Company can implement a Medically Managed Plan. Both Private and State run companies have the option to pass this Plan onto their customers/members.

Medically Managed means the Insurance Company has employed their own Physicians to oversee such things as therapy. They basically tell us we have to submit copies of Evaluation reports, treatment plans, and session notes and then they determine whether or not a therapy is MEDICALLY NECESSARY.

If therapy is authorized, we see the child for up to 8 visits and then request further visits. If enough progress is shown, further visits are granted. As I am finding out to be true more and more, most of these Medically Managed Plans are saying “NO” to therapy! I have been told by certain insurance companies that especially for children with a medical diagnosis involving long term issues, we should not expect the insurance company to cover the therapy as an ongoing treatment.

The scenario goes like this. If a child falls and breaks a bone and requires Physical therapy to help the healing process, the Insurance Company is more than willing to pay for the Therapy. They are agreeing to a “short term fix and a long term solution.” An end result so to speak. Medical necessity. If a child has a predetermined diagnosis of, say, Cerebral Palsy and requires Physical Therapy in order to keep his legs stretched your medical insurance may determine said therapy to be NOT MEDICALLY NECESSARY because there is no long term fix with an end result/solution. Basically the insurance company wants us to FIX the child, and if and when we can’t the therapy no longer becomes necessary.

They feel we are expecting the Insurance Company to agree to MAINTENANCE therapy, and that is just not something they are willing to pay for. From my standpoint, that is a very sour pill to swallow. I can’t imagine a parent hearing those words when referring to a child!

And, the saddest part of this is that not all insurance plans fall under this authoritarian rule so to speak. We may have two children with the same diagnosis, and one child is entitled to receive 60 visits per year, and the other child, because of a Medical Managed Plan, is entitled to only 6 visits per year! This is not to say we have never been granted further visits by the Insurance Company Physicians, the numbers are just few and far between.