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.