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In this “post-pandemic” era there is a multitude of reasons why a child may be needing extra help moving from diapers to flush. Whether it’s that parents were working from home previously, or they have been at school and schools have been overwhelmed with kids needing to move toward toileting independence, or that special needs positions have remained unfilled. A brunt of families are feeling like this “should” have been done before now, by occupational therapists, by school teachers, families, and by co-parents. But, we all know, it’s not always that simple. When you need to reach out for help, is there financial assistance for you to even do so? What are your options in 2023?
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Whether you are looking for in-home potty training help (a professional potty trainer who can come to you), or help via phone/video chat, we are here to help. Though most of our clients simply book these consultations directly with us (you can do that here), some clients have more specialized situations that may need the support of insurance or even a school stepping in to help with the cost of the investment. It truly is an investment that will keep paying off for years to come.
With a sudden rise in the demand for professional help with potty training, one of the frequently asked questions is if potty training is covered by insurance, HSA, FSA, or by a public school through a child’s IEP or 504.
Although our home consultation packages aren’t covered by insurance, they are often covered by FSA and HSA. Most of our clients can use their FSA or HSA benefits to pay for our help with potty training. And, keep reading if you are looking for a school/school district (via an IEP or 504) to help cover the cost.
A few things to remember:
Like many things that require pre-approval, it can be a process. That said, you may want to pay your non-refundable deposit out of pocket to secure your date ahead of time and while waiting on pre-approval. If your FSA or HSA plan decides to cover the rest, we're happy to accept payment that way. If you are unable to pay your deposit out of pocket, then you will need to wait for the approval request to actually be approved (in writing from your administrator) before booking.
If your administrator requires for your to pay out of pocket and then submit a receipt, then you will need to hang onto your invoice. The Potty School does all of its invoicing digitally, so just keep it in your email inbox and search for "@thepottyschool.com, or we can resend a copy if need be. That said, you may need to pre-pay for your potty training services ahead of time and then submit your receipt and you personally will be paid back by your administrator.
Your administrator probably doesn't care how you pay your bill originally (credit card, debit card, etc.), because they will be paying you back. If necessary, we can provide a certification of hours completed if your administrator requests that.
Your insurance may require your healthcare provider (typically your pediatrician, or pediatric specialist) to provide a letter of medical necessity.
This needs to be specific and beyond a brief description saying you need help potty training. They may list what (medically) has already been tried and the outside resources you have already sought and then the rationale as to why The Potty School is the best fit for the issue at hand.
Namely, we provide one-on-one personalized services. We are specifically trained in potty training and pottying-related issues. We happily refer to physicians when medical needs arise, but in the same regard medical professionals, and even university hospitals, often refer to us when the issues go beyond the scope of what their general, or specific expertise is in. Letters of medical necessity can come from your primary care provider or a specialist.
This is what we do day in and day out. We have numerous suggestions and options up our sleeves. To obtain a letter of medical necessity, you can visit, or contact your pediatrician's office. They should help you to be able to coordinate.
Example of a Letter of Medical Necessity for potty training services at the end of this article.
Insurance companies don't get a plethora of requests for help with potty training. It can be a little confusing for them to navigate the process because it very well may be their first request. The categorization is a little fuzzy. Sometimes it can be labeled under "pediatric care", "Health Institute Fee" or a variety of other categories until an actual potty training category is created and a billing code associated with it. Until then, they may need to be creative in how to code your services correctly in order to provide your family with the help it needs. Different insurance companies will code it differently, so we don’t have a one-size-fits-all answer for you.
If you are seeking medical insurance to cover the cost of your professional potty training help with The Potty School, then it needs to be a medically relevant problem. Depending on whether your child has insurance coverage for mental health as well as with their medical coverage would determine if mental health-related issues were covered. For example, but not limited to victims of sexual assault now suffering PTSD, or selective mutism.
Insurance considered a few factors when deciding who to cover for these extended benefits. They will look at your child's medical history. They will require some sort of physical examination (that may be covered by your typical well-child check-up), and then they will decide who is the medical decision maker about this subject for your plan. From there they will code it for billing so that it can be properly processed.
The main need is "medical necessity of criterion", meaning, is this service medically needed? Another question they ask is if this service can be filled in a less-invasive, and more cost-saving method. If you are consulting with a GI monthly and nothing is being resolved because there needs to be more in-home support, this may be a situation where our services may be approved by insurance because it's not reasonable and is cost-prohibitive for a GI to spend several days in your home.
Once more families start requesting their insurance to approve The Potty School for potty training consulting services, there will be more of precedent set with insurance companies regarding whether or not they "typically" approve or deny the request for a potty training expert or potty training specialist. Once that happens it is common for families to be tempted to over-document why they should need the services. Typically, they just want to hear from three entities. For your family, the "proof" that you need help may be a letter of medical necessity from a specialist, from yourself stating your experience and what you've tried, and from one other professional. That could be anyone from a school teacher or a school district or even a paraprofessional to someone who owns a gym your child works at or a behavioral or occupational therapist. You don't need letters from them all. If you spam the insurance company they aren't more likely to approve your services, but it is more likely to take longer. If anything, if they deny your request for home or phone/video chat/Zoom potty training consulting, you can appeal the decision.
You need to follow the appeals procedure that your insurance company has. Often times a family can appeal with additional paperwork. This would be the time to submit information such as "logs" that document the number of accidents occurring in a classroom or at home. It would be time to document the additional resources currently being used in order to help with these situations such as recurring visits to a gastroenterologist or urologist, urgent care, or an emergency department. This is helpful because it helps them to value the situation's gravity, and the monetary implications of not approving the request for professional potty training help is already having on their company.
Insurance companies don't get a plethora of requests for help with potty training. It can be a little confusing for them to navigate the process because it very well may be their first request. The categorization is a little fuzzy. Sometimes it can be labeled under "
Check with your program prior to paying for a potty training consultation, but you should be able to directly pay with an HSA debit card, and with prior approval, you should be able to pay with a FSA.
If your child has an IEP or 504, you can go that route as well. We discuss that more below.
"Maybe" is the definitive answer. We have had clients add potty training to their IEPs after consulting with us. We have had families request professional potty training help with The Potty School because their child has a 504. It really depends on the severity, how much the problems impact your child's educational goals, the state you live in, your school district, your past IEP or 504 goals, and the school's availability to provide one-on-one or group support directly to parents. We are contracting witht he department of health services in select states to provide services that way as well. That said, you can definitely ask your school at your next IEP meeting (or before! You can request mid-year updates) to include potty training as a goal. You work with your team to set specific goals within reasonable timeframes. If your timeframe is that your child will be out of diapers within a year, then backtrack and figure out together what a quarter or semester, or trimester goal would reasonably look like. If your school is unable to attain the goal after the first segment of time, it is very reasonable to ask them to include in your IEP (Individualized Education Program) professional potty training consultant, such as The Potty School. We have another article here for them to review about what we suggest families look for in a potty training consultant. A parent can ask the administration for outside potty training services to be an approved professional service in the 504 plan. Even if you are waiting on an IEP meeting or a 504 plan review, you have the right to request a meeting/review between now and your next set time of review. There is no requirement for what is included in a 504 plan, that said, a potty training accommodation or goal is within the realm of possibility. Generally speaking, a school can only bill your insurance with written consent, so that’s something to keep in mind as well.
SAMPLE: LETTER OF MEDICAL NECESSITY
PHYSICIAN’S LETTERHEAD
[Date]
[Payer Name]
ATTN: [Contact Title/Medical Director]
[Contact Name (if necessary)]
[Payer Address]
[City, State, ZIP]
Re: Letter of Medical Necessity for [Potty Training Service]
Patient: [Patient First and Last Name]
Date of Birth: [MM/DD/YYYY]
Subscriber ID Number: [Insurance ID Number]
Subscriber Group Number [Insurance Group Number]
Case ID Number [case ID number (if available)]
Dates of Service: [Dates]
Dear [Contact Name/Medical Director]:
I am writing on behalf of my patient, [Patient First and Last Name], to [request prior authorization of/document medical necessity for] treatment with [The Potty School’s service]. This letter provides information about the patient’s medical history and diagnosis, and a summary of the treatment plan.
Patient’s history - clinical
[Patient’s Name] is [a/an][age]-year-old [male/female] patient who has been diagnosed with [condition] as of [date]. [He/She] has been in my care since [date], having been referred to me by [referring physician name] for [reason].
[Brief summary of rationale for treatment with [potty training service]. This includes a brief description of the patient’s diagnosis, including the ICD-10-CM code, the severity of the patient’s condition, prior treatments, the duration of each, responses to those treatments, the rationale for discontinuation, as well as the other factors (eg, underlying health issues, age) that have affected your treatment selection.]
Treatment Plan
On [Date], the FDA approved [potty training service] for the treatment of [indication].
[Include plan of treatment (dosage, length of treatment) and clinical practice guideline that supports the use of [potty training service]. Consider mentioning experts in the field who also support the treatment.]
Summary
Based on the above, I believe [name of The Potty School’s service] is indicated and medically necessary for this patient. If you have any further questions about this matter, please contact me at [Physician phone Number] or via email at [Physician Email]. Thank you for your time and consideration.
Sincerely,
[Physician Name and Credentials]
Enclosures
[List enclosures, which may include: prescribing information, clinical notes/medical records, diagnostic test results, relevant peer-reviewed articles, scans showing progressive disease, pathology reports, etc..]
