Navigating insurance companies for your TBI loved ones, is like trying to separate the wet mess of hairs that get clogged in a shower drain. It takes a lot of time, a lot of patience, a steady hand, and even with all of that… it’s nearly impossible.
Even with all the knowledge I’ve acquired, I still made some mistakes this past week in trying to get Patrick post-surgigical acute rehab. And by mistakes I mean, I didn’t “hawk” people early, quick or often enough.
There are a thousand ways that insurance companies can screw you. This post is geared specifically towards those who are trying to get their TBI loved ones (that are past the 1-2 year mark and have made considerable progress), acute rehab care after a surgery knocks them on their butt.
1. KNOW THE GAME: First things first. Your ability to get acute therapy is going to depend on several things, but the most heavily weighted factor will be your insurance company. Obviously the better your insurance company, the more likely they are to approve a deserved acute rehab stay. In our case, Patrick has Medicaid, which is notorious for approving as little as possible. Be prepared to fight hard for your loved one.
2. KNOW WHAT YOU WANT: Acute therapy is the most intense and hardest to get; 3-4 hours a day in an inpatient setting, often in a rehab facility. Sub-Acute therapy is typically 1-2 hours a day in typically a “skilled” nursing (AKA nursing home) facility. Home Therapy is what it sounds like; therapists that come into the home from an agency to work with your loved one. Out-Patient therapy involves traveling to a facility, usually 1-3 times a week. I could write a whole blog on the intricacies of what each of these levels of care entail, but for now, we’ll look at what Patrick and I were seeking out; acute therapy.
3. ACT FAST: As soon as your loved one is admitted into the hospital, you want to begin advocating for acute therapy. Take your place at the helm of the ship and begin to steer it in the direction you want. Inform the attending physician and surgeon that you want to pursue acute inpatient therapy. Get them on all board as quickly as possible so everyone is on the same page.
4. ASK FOR HELP: You want to request a meeting with a social worker and case worker quickly as well. The hospital will not make you aware of your rights, but you have the RIGHT to this help, and it is THEIR job to navigate this process. Once you meet them, re-state your reasons for pursuing therapy. Be approachable & passionate. Thank them for their help in advance. Make them believe in your loved on. Get them on the team.
5. LEARN THE LANGUAGE: Everything comes down to how the report from your doctors and therapists are worded. Ask for a consult with the PT/OT department and convey the plan of action. Inform them of your insurance policy upfront, because every company has arbitrary cut-offs that delineate acute, sub-acute, home care and out-patient. They won’t know what your company’s cut-off is, but they can get an idea from the insurance plan. For instance, with our insurance, if a patient like patrick “ambulates more than 50 feet” he is not considered a candidate for acute therapy. Patrick walked 80 feet, and they wrote that in the report. If I had met with the PT prior, we would’ve discussed this, and she would’ve only walked him say…. 40 feet, so that technically she could write in the report that he walked 40, without having to lie and say he couldn’t walk more. Essentially, her intentional ignorance would’ve been our bliss. Regardless of what they find in their evaluation, just about anything can be worded in such a way to make the case for acute care. This goes the same for the doctor’s report. However, you have to KNOW the language of the game if you want to win.
6. MAKE NO ASSUMPTIONS: Most therapists are not familiar with TBI, and insurance companies know next to nothing. Even some doctors/surgeons are not familiar, as they do not live with the chronic symptoms associated with TBI. They will treat your loved one the same way they would a person who just had surgery and was not suffering from the complex challenges of TBI. You must educate them.
7. MEDICAL COMPLICATIONS WONT JUSTIFY ACUTE THERAPY: Patrick had a pic-line in, was receiving IV antibiotics, was at high risk for a seizure and infection, had difficulty walking, decision making impairment and had just had surgery, but none of that was enough to justify acute care. The insurance company denied him, and when I appealed it, they claimed that all my concerns could be addressed in sub-acute with less therapy.
8. TALK UP ANESTHESIA, REGRESSION & A BASELINE: Many new TBI patients who go through surgery will receive acute care because insurance companies can justify that the patient has “room for growth.” When they have additional surgeries, however, 20 months post like Patrick, they will make the argument that they have reached a “baseline,” and that there is no longer any room for growth (which is not true). This is why you have to prove to them that the anesthesia administered to your loved one has caused their injured brain to regress. Talk it up to the therapists, doctors and social workers. Tell them what he/she could do prior to surgery and cannot do now. To sum: regression is the key.
9. YOU CAN APPEAL THE DENIAL: If your request if denied, you can appeal it. The first step is a peer-to-peer review. Your doctor will call the doctor who refused the request at the insurance company. Make sure you have another pow-wow with your doc, stressing the need for acute care. I gave our doctor a piece of paper with bullet points. He called me at midnight to go over everything. You can also make an appeal yourself and provide an addendum with documentation from a second PT if you request another eval. The more doctors who provide documentation the better, but this takes more advocacy on your behalf.
10. DON’T BE AFRAID TO RAISE SOME HELL: When our doctor tried to do the peer-to-peer review, he got bounced around the phone line for 25 minutes before being dumped into voicemail. I called the company myself and got the same treatment. Sometimes you have be a little crazy to turn some heads. I threatened to go radio, TV, newspapers and even Facebook if my appeal wasn’t processed immediately and the denial overturned. And wouldn’t you know it.. I had a supervisor on the phone in a matter of minutes.
11. DON’T UNDERESTIMATE THE POWER OF YOUR HUMANITY: It’s equally important to know when it’s time to super approachable, sweet and grateful. This comes down to your own intuition. I needed to use rage with the insurance company, but when I finally reached the supervisor, I totally changed up my tone and approach, to a human-to-human desperate plea.
12. ADVOCACY IS ESSENTIAL: In the end, it’s important to know that absolutely nothing will get accomplished unless you are willing to fight extremely hard for your loved one. Don’t expect for a second that anyone will do the homework for you, or that your loved one won’t fall through the cracks. They can and usually will if you don’t plug up the holes yourself. Don’t take no for answer.
In our case, it was a struggle, but we got him 7 days of inpatient acute rehab. After 8 days laying in bed fighting infection, he would’ve been left far worse than when he entered without the acute therapy, and it could’ve taken him a long time to regain what he lost. With the intense daily therapy, we stand a good chance that he can make back that ground fast. And hey, that was what the plan was all about.
I hope this advice has been helpful! Good luck my fellow warriors. Advocate, on!