This information pertains solely to our practice at Pediatric Building Blocks.
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This information pertains solely to our practice at Pediatric Building Blocks. |
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A Statement Regarding Medically Necessary And Educational Therapy Medically necessary therapy is prescribed by a physician, normally for a specific disability or condition. It is best done at a medical facility where physician’s can determine if therapy is meeting their expected goals and outcomes, or in a private clinic that works directly with the prescribing physician. There are specific expectations regarding medical therapy, which are monitored by the referring physician or insurance underwriter, for expected outcomes. When insurance companies are involved, therapist are required to justify the cost and outcomes. The laws changed in January 01 and many of our clients have been successful in getting private medical insurance to pay for this service for disabled children. However, they all face specific time limits, and therapy is not provided on an ongoing basis. The primary aim of Occupational Therapy as an educationally related service is designed to enhance the student’s ability to participate in the educational program. In the school setting the question asked is whether services are necessary for the student to meet educational goals. Occupational Therapy in this setting is not intended to optimize skill level, but to assist the student in developing foundational skills necessary for him or her to purposefully interact and benefit educationally in the instructional program. Test scores are not viewed alone in determining the need for services but are considered in the context of many other issues including, but not limited to overall function, specific educational goals and objectives, and/or class placement. Occupational Therapy services can be provided through direct services, monitoring in the classroom, consultation, or a combination of these services, depending on which will best serve the needs of the student. If a family presents the school system with a prescription for occupational therapy from a physician several questions are asked:
The questions are reasonable in that "education" is the business of the public school system. In the school system, therapy is warranted based on academic function. It is the responsibility of the school district to determine whether or not it is acceptable to honor a physicians prescription for Occupational Therapy in the schools. If the student is learning, receiving benefit from instruction, if the support they need, can be provided by classroom staff, or other IEP team members, then direct OT services are not warranted. Which does not mean the child does not need therapy. Only that it is not appropriate for the public school system to pay for it because the student is receiving benefit from educational instruction as part of their free and appropriate public education. It is not the responsibility for the public school system to pay for non academic or private therapies that are not required for academic benefit. In the private sector (for insurance companies, who offer coverage) therapist’s are required to report to the physician or facility on a regular basis, and there must be an expected outcome stated. They receive permission to continue services from the physician or insurance company for a specific number of visits or length of time. Private insurance very seldom offers more than six to ten initial visits when there is limited progress toward expected outcome. When no progress is made therapy is discontinued completely. Pediatric Building Blocks provides therapy as long as it is ethically appropriate. Whether for medical, private, or academic service, we monitor for expected progress. Maturational growth is not considered progress, nor is it considered a result of therapy. A years growth in a years time, is maturational growth. |
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