Sensory processing eval w/o diagnosis?

[4KookieKids]

So our family therapist who we've seen for the last 3-4 years has said it's quite likely our oldest is on the autism spectrum (bright, but lots of social issues, fixations, and complete chaos if we deviate from the routine). For now, since we homeschool, noone involved (us, her, our normal ped) is inclined to go for a diagnosis. But she did encourage us to get evaluated for sensory processing issues from an OT. Thank you very much.

 

Well, I found one and called them, and was told that sensory processing issues are not considered their own thing (yet, though the medical community will hopefully get their act together) and in the meantime, in order to do an evaluation, it would need to be under some other diagnosis (autism, adhd, fine motor delays, etc.)

 

Does anyone have experience with this? I feel a bit overwhelmed with information and unsure of what to do.

 

I should add that he definitely has some issues with clothes (wanting "soft" ones), food (lots of issues gagging, even when he's not complaining about food), and being distracted (art on the wall, for instance - I've walked into the room and found him hunched over his work with his hands shielding his eyes, and asked him about it to get the explanation that the pictures on the walls were just too distracting for him to focus on what he was doing).

Edited September 29, 2016 by deanna1ynne

[Lecka]

I think call back and see if they meant for insurance coverage, or to see you at all.

 

I would be surprised if they won't let you self-pay for an eval or initial appointment of some kind. But then you are doing self-pay.

 

For insurance coverage, if she would qualify for diagnosis for autism, and that would lead to insurance coverage for OT, that may be a route where you don't self-pay.

 

If they really won't see her, I would ask them why not. I can guess some reasons but I think they might say why they have that policy if it is a policy.

[Lecka]

But my first thought was the receptionist had in her mind, you wanted insurance to

pay for the evaluation.

 

Then maybe you need a referral from your physician saying "fine motor concerns" and then your insurance pays.

 

If she said things like "here are things that are covered" maybe you need a referral mentioning one of those things.

 

But if you want to self-pay, maybe explain that and see if it makes a difference.

 

It is my guess for most likely.

 

I have to make multiple calls sometimes! Just bc I am missing some basic point, or got confused. I think receptionists are used to it!!!!! And often they are also the people who bill

insurance, and so they get asked a lot of insurance questions. So I can see that happening really easily.

Edited September 29, 2016 by Lecka

[Lecka]

For me when I need a paper trail it is either the school IEP, or a physician referral. There are places that require one or the other, usually bc they are specializing a bit and don't want to waste everybody's time if it is not the right appointment to have.

 

But I do think most places don't care if you are going to self-pay.

 

But in a way I think it sounds like a high-quality place if the reason is they don't want to waste people's time.

[Lecka]

Another thing I thought of that would make sense -- maybe they tailor their initial evals a bit by diagnosis? Maybe they assign a certain person or consider different screenings or whatever. But it seems like you could work that out with the receptionist, maybe.

 

Sometimes it is hard to communicate with them when you don't know the system and what your part in the interaction is. But this is where I call back and ask again. Maybe say things like "would it be helpful if I...."

 

I don't think anybody already knows how to do this stuff the first time they go, and you might be "self-referring" which I think might be less of a system than when you come with a physician referral or other paperwork and fit into the box for them a little more clearly.

 

You might ask the difference and decide if you want to go back and get a physician referral.

 

If you actively don't want her diagnosed with anything, then you may want to ask questions about what will go on her paperwork. You can decide that when you are self-paying.

 

When you are going through insurance I don't think there is the same kind of privacy.

 

I don't know too much about it.

 

I have seen things where people self-pay in general though so they can control all the results and who they are shared with, and I don't really know much about it, but I have heard of it.

 

I have always gotten the referrals and have the paperwork trail.

 

I don't think it is a big deal, but some people do.

 

But if that is not an issue, maybe talk to your pediatrician's office. At ours front desk staff can handle some inquiries about referrals. Sometimes I need to make an appointment to ask for a referral, sometimes I say what is needed and someone types it up and having s the Doctor sign it, and I don't need to go for an office visit. If you have discussed any of these concerns and they are in the notes or whatever, maybe you don't need an office visit.

 

It is not as bad as it sounds.

 

Your insurance may work a different way but that is how ours is to some extent. I just ask people and then sometimes call back. Sometimes I need to ask the doctors office to use specific wording that the people at the specialist's office know will go through insurance (bc they do it all day and the people at the doctor's office may not know certain wording).

 

But really it is not as bad as it sounds!

[4KookieKids]

You're right. They only need a diagnosis for insurance to cover it. So I'll check out the cost to self-pay for just an eval and go from there. Thanks! I would never have thought of that on my own. :)

[TrixieB]

I will add one thing about self-pay.

 

If the provider is made aware that you have insurance, and they are contracted with your insurance plan, I believe they are not permitted to accept you as a cash patient.

[Tiramisu]

You're right. They only need a diagnosis for insurance to cover it. So I'll check out the cost to self-pay for just an eval and go from there. Thanks! I would never have thought of that on my own. :)

Maybe I'm missing something. If you have insurance, why not let insurance cover it? OT evaluation is hundreds of dollars where I live.

 

This isn't such a big deal to come up with a diagnosis based on symptoms. Primary care providers have to do it all the time for referrals because when you first make an appointment for any kind of specialist, you don't usually have a clear diagnosis beforehand, just some symptoms and suspicions, whether it's OT, cardiology, neurology, gastroenterology, etc.

 

The people who make referrals are experienced with this and it's usually easy for them to find a code that can fit to cover it.

 

I wish I could remember what reason was on the referrals for all the OT we had. Once it was AHDH for one kid who it turns out doesn't technically have ADHD. But we've gone three other times with other kids and I have no idea what the primary used. For the neuropsychologist evaluation, the code for the referral was a head injury from years ago and headaches.

 

I would always try to get a purely medical reason down for the evaluation because that can avoid issues later. I wonder if a motor skills problem would be a good bet??

 

Also, I think we've needed authorizations for OT evaluations. So if there are any issues that come up you can trouble shoot.

Edited September 30, 2016 by Tiramisu

[Tiramisu]

Rereading, I see you are disinclined to go for a diagnosis. It's your choice. But I would consider it now and again and again as the years go by, because the social stuff and anxiety can really get worse as you get into the teen years. So keep re-evaluating whether this is in his best interest.

 

I'm very sorry if this sounds harsh or judgmental, and I din't mean that. I only say this as someone who did not get any of our diagnoses early and saw my kids suffer for it when they would have been helped by getting appropriate interventions earlier.

 

But it's very hard for even specialists to understand the needs of higher functioning kids because they tend to be rather well-behaved one on one and they don't often get to see what really happens when a kid like this gets stuck. I also think regular therapists have a typical developmental trajectory in mind and don't appreciate the extent to which ASD kids can deviate from their typical peers in their development more over time without the right support.

[PeterPan]

That's probably why you're not getting a lot of replies, btw.  I see how that works out in the homeschool community, not getting a diagnosis, not getting connected to resources, not using the up to date, best resources, and I don't like how it turns out.  Now there are lots of paths and opinions, sure.  I just think getting an actual diagnosis gives you the most options.  In our area, it comes with county level disability funding, state level disability scholarships, disability access at public places, an established paper trail if we have problems in public and have to explain what's going on to authorities.  There are so many GOOD reasons to get evals.  And I have many friends (with a variety of SN) who are anti-evals, so I get it.  I'm just saying later on it becomes obvious why the evals would have been good, at which point it's really late.