My son is 3 years old and he doesn't talk. He's was in speech therapy through SoonStart/Early Intervention until his third birthday and has since been going to speech therapy through a private company. Both SoonerStart and his current therapist believe he has autism, his ped also believes he has autism, but wouldn't give me a referral to a developmental ped because the resident said no. I have made multiple attempts to get a referral to a specialist, but the dr's office always refuses. So, I was wondering if I could take him to a specialist without a referral and it still be covered by insurance. His insurance is through SoonerCare/Medicaid.
Do you have some other coverage than a PPO? With my Aetna PPO, I can self refer anywhere. If this isn't an option get a new ped who will refer you.
Good luck!
Call and ask the insurance. If you need a referral and your pediatrician denies you find a new pediatrician.
You need to col your insurance company and ask. But if your pedi thinks he has autism and won't prefer you, find a new pedi! It's not supposed to be that hard to get help.
Why is your pediatrician denying you this? It seems odd and it makes me think there is more info to this story. I would find that out first. What does his current therapist say about this situation...does she have any suggestion of where to go, has she contacted your pediatrician's office?
I think it just depends on your insurance. Give them a call....
We got a referral to Children's in OKC and it was going to be almost a year to wait for the appointment. There are only 2 in the state. Call the county health department and ask them about developmental evals. They are done by non-professionals but they give you a lot of insight and the tests they use pinpoint what it is very well. We used the one in my area and she gave head start teachers questionnaires and me and hubby ones individually. All of our answers were almost universal so the eval was easy.
He was assessed to possibly have Sensory Processing Disorder. She gave us a lot of ideas such as putting a weighted vest on him, letting him bounce on a mini trampoline as much as he wanted, rocking him when he got upset, putting tight fitting clothes on him, etc...we tried all of them and found some things that really helped.
We wanted to get a professional to evaluate him and diagnose him but again, it was going to be nearly a year wait for the appointment. We are having the school psychologist do the evaluation and diagnosis this coming year during pre-k.
If your pediatrician won't do it then call your insurance provider and see who they recommend for the diagnosis evaluation. If they say they have to have a doc's referrel to issue payment then you are certainly stuck. If they will pay a doc that will accept you but the doc won't take him without a referral then again, you are stuck.
In this case I would think it would be time to change to a different doc just as long as it takes to get the appointment. Pin your doc down too, tell them that you want a referral to Dr. XXX that your insurance suggested that accepts your insurance and if they are not willing to do so then can they get your records together so you can change to one that will.
Good luck, I know the not knowing and wondering what is the real issue can be overwhelming and tiring.
Well, I think it's BS that the pediatrician won't give the referral. If you can, I would definitely be looking for a new pediatrician. As far as your insurance coverage, that question is best asked of your insurance provider. Health insurance providers have some weird rules and all the plans are different depending on many different factors. I have given up trying to figure them out and I always just call them if I have a question. If I'm not satisfied with the quality of the answer I receive, I call back and talk to someone else. Explain your situation to the insurance rep, maybe someone can get the referral on your behalf.
Wait....you all think he has a serious developmental disorder and he is only getting speech therapy??? Why isn't he in your town's preschool? Why wont the doctor give you a referal since he thinks your son has autism? If your son indeed has autism, you need to get him specific therapies immediately. Sometimes insurance requires the referal, other times no. Does the developmental pediatrician require the referral? I think you should demand one.
My daughter has Down syndrome and is on soonercare. I think you do need a referrel for the developmental ped. You can also call the develpmental ped office and ask them. They will tell you what you need to do. I would also call Soonercare and tell them that you would like to switch your primary care provider. They will do it if you ask. There are some good ped. in the area that accept Soonercare! Does Soonercare pay for your sons speech therapy? If your ped will referrel you to the speech therapist, then it will pay for speech, occupational, and phyical therapy.
Medicaid won't pay for some things even WITH a referral.
You can try taking your child to a different pediatrician for a second opinion and perhaps get a referral that way.
I don't know how it works in Oklahoma, but I'm in California and had Medi-Cal (medicaid) after breaking my leg. I had to wait over 6 weeks just to get an authorization for physical therapy with a doctor's referral and even then, there was only one physical therapy provider that would take medi-cal patients so I had to wait another 3 weeks before they could even get me in for an evaluation. It was another couple weeks before they could start scheduling my therapy because they were booked that far out.
When you have medicaid, you have to jump through their hoops or they won't pay.
I think you need to find another way to get a referral and also check around to see if there are even specialists in your area that will take medicaid.
Many won't.
Best wishes.
Call the 800 number on your insurance card, they are the ONLY ones who know for sure...some say yes some say no, it all depends on the type of coverage that you have. We have Medicaid for our grans & the booklet they sent is like a horror film of do's & don'ts but when we take them the story changes according to what the Dr. says is best for them, this is AL & each state is different. You also might want to ask for a second opinion within the paramiters of your medicaid, it's definately worth the phone call & you may end up having to take your child to your closest University Teaching Hospital for a work up but, that would be a good thing.
Best of luck to you & your little one, Blessings...A.
