Writer’s note: This story is the continuation of Dr J. And The Next Six Months, and continues to chronical the process we go through every 6 months to justify the treatment our son recieves. I have decided to document our current renewal to show you how we go about getting our Medical Assistance Behavioral Health Management Organization (yes, they make HMO’s for behavioral health too) to authorize and pay for Behavioral Health Rehabilitation Services, which is just a fancy phrase for therapy and behavioral support provided where the child needs its. Like at school, or in the home, or even out and about in the community. This documents the the first part of the process, the evaluation for services. When you are first coming into the system, the psychologist will have an intake appointment to help assess the child, and families, needs. If the psychologist decides that BHRS is needed, then they will have a separate BHRS evaluation appointment. This post talks about the last evaluation PT had. I was there, as was his current BHRS service provider, Mr. M. I will be continuing this series throughout the renewal process. There are a number of meetings that take place and I aim to outline all of them so you can get some idea of the process.
Last time I talk about the evaluation with Patrick’s psychologist Dr. J. Well that is only the first part. Once the evaluation comes back then the real fun begins. When Mr. M, PT’s Behavior Consultant/Mobile Therapist, comes to visit we share the report with him so we can begin to talk about how we want to write up the treatment plan. This doesn’t really happy at a formal meeting, in all truth, we have been discussing this all along, constantly trying stragities and refining them feedback from us and PT’s teachers. But we do sit down to informally review the treatment plan and make sure everything we want covered is covered. Then comes the “fun” part (and yes the double quotes are ment to invoke sarcasm). Next up is what we call the ISPT meeting or Interagency Service Planning Team meeting. This meeting includes not only the parents, but also the lead therapist (Mr. M), the Service Coordinator (aka Case Manager), and can even include teachers (if there are dedicated services at the school or they want to participate), and the insurance company (if the bother to call in or attend at all). Our meeting consisted of me (The Mommy couldn’t get off work), Mr. M, and PT’s case manager who is a wonderful woman who goes out of her way to come to all our IEP and ISPT meetings. The insurance company did not attend, and while the medical and psychological professionals are welcome to attend, they are usually unable to due to their schedules.
At this meeting we layout all of the progress that occured over the last 6 months. This time we talked about PT making friends at school and starting to play better with his peers. We also talked about how good his academic grades were and how well he did with summer school, and how it was a great idea and really helped him with his social skills, sharing, and taking turns, all areas he struggles with. We also talked about the problems we are still seeing like the “nuclear meltdowns” he has had, the self-punishment involving hitting, biting, and slapping himself, and his continued domination of play. We also talked about the continued potty training issues we are seeing and a few other issues the school has been dealing with.
After we set the stage with the good and the bad, we talk about the prescription and what the Psychologist wants the treatment team to work on. Once we get that out of the way, we talk about how the treatment plan will address these issue. For example, the treatment plan has a crisis management plan. This plan lays out how we can try to stop the “nuclear meltdown” before it goes nuclear, and if we can’t how we deal with that. This plan also talks about behaviors in measurable terms like, “When at home and the community the parents will provide tolieting oppertunities at approxamately every 2 hours and he will comply 75% of the time”. There are also behaviors plans for school and the community enviroments on all the different issues PT has. Once we all come to an agreement on this plan, Mr. M packages everything up and turns it into the insurance company for final approval.
Finally, after about a week or two, the insurance company sends back a notice that they either approved the plan as written, partially approved it, or denied it. If they partially approve, or deny it then we have to appeal. The appeals process and my frustration with the insurance company was documented in an earlier post two posts called “It Came On Saturday” and “Appeals Update”. I hope you never have to deal with that, but if you do you at least have some idea how it goes.