Insurance claim backlog jeopardized treatment for child with Down syndrome

The Leones are a picture of an all-American family. Dad is a firefighter and mom stays at home with their two children.

But on top of everything else a mother has on her to do list, Allison Leone has spent much of the last year battling with Blue Cross Blue Shield of Florida (Florida Blue) to get claims paid.

Her 6-year-old son, Max, has Down syndrome. For the past year and half, he’s been going to specialized behavioral therapy at Focus, a multi-disciplinary pediatric clinic in Fort Myers.

Max is getting advanced behavioral analysis (ABA therapy) and his mom says he’s thriving. Before coming to Focus, Leone says Max couldn’t even sit still long enough to do a simple learning exercise.

Their goal is for him to be as independent as possible, so the Leone’s enrolled for a higher tier insurance plan that covered ABA therapy.

But, for nearly a year, Focus says Florida Blue hadn’t paid a single claim for his care.

“They [owed] us around $20,000,” said Jennifer Volz, the speech pathologist who owns Focus.

Volz said the problem is not that the Leone’s plan does not cover the therapy. It is a covered expense. The insurance company requires practitioners to be in network. Even though she is in network, the specialty therapist overseeing Max’s care was a new employee and had not been credentialed into the Florida Blue system.

So, for months, Volz’s staff has completed paperwork to alleviate that issue. But she said, as soon as one requirement would be met, Florida Blue would confront them with another.

“It’s been a circus, literally, chasing tails,” said Leone, who has been making her own calls to the insurance company to try to get the claims processed.

In late January, Volz emailed the Leones to tell them she would have to put Max’s therapy on hold until Florida Blue paid the claims. February 1 would have been his last day.

WINK News contacted Florida Blue about the situation, and Leone said the company got in contact with her within 24 hours and promised to get the claims paid so Max’s treatment was not interrupted.

On January 30, she said Focus received a wire transfer to cover the full amount of past due claims.

A representative for Florida Blue said it is the company’s policy to not discuss personal medical information with the media.

Blue provided the following statement:

Florida Blue’s mission is to help people and communities achieve better health, and that is only achievable by partnering with quality health care providers. We value our relationship with the doctors and health care professionals who care for our members day after day. We process tens of millions of claims from them each year without issue. Despite our best efforts, there are occasionally complexities in the process that cause inefficiencies. We are addressing the experience of this health care professional while also conducting a thorough evaluation of our procedures to avoid similar situations in the future. We are committed to improving our processes to better serve our members.

WINK News is taking an in-depth look at health care in our new Cost of Care series. If you have a story you want to be heard, whether it’s a high medical bill, an insurance dispute or a medical procedure gone wrong, send us an email to [email protected].

Reporter:Lauren Sweeney
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