Rehab facility denied by insurance--what next?
August 28, 2023 5:56 AM Subscribe
My 81-year old mother recently was admitted to the emergency room with spinal stenosis that suddenly left her unable to walk. She had spinal surgery (ACDF) and was sent to rehab for PT/OT. I was reviewing her mail today, and it seems rehab was denied by her insurer. What next?
This is the first time I am taking this kind of active role in my mother's care--both because of the unexpected hospital and rehab stay and because she is not as sharp as she once was.
It is crazy to me that the insurer would deny rehab to an 81-year old who cannot yet walk or care for herself after getting emergency spinal surgery, but they quote certain medicare standards in their denial letter.
And, of course, she has been in the facility for over a week at this point, perhaps racking up huge bills!
I have a healthcare proxy, but I'm not certain I am delegated to negotiate with the insurer (will double check the rules).
How does one challenge these findings? Do I go through the rehab facility where she is staying? The surgeon (who has been caring for my mother for related issues for a while)? The hospital, or the patient advocate who had been working with my mother while she was recovering from surgery?
Many thanks for any guidance!
This is the first time I am taking this kind of active role in my mother's care--both because of the unexpected hospital and rehab stay and because she is not as sharp as she once was.
It is crazy to me that the insurer would deny rehab to an 81-year old who cannot yet walk or care for herself after getting emergency spinal surgery, but they quote certain medicare standards in their denial letter.
And, of course, she has been in the facility for over a week at this point, perhaps racking up huge bills!
I have a healthcare proxy, but I'm not certain I am delegated to negotiate with the insurer (will double check the rules).
How does one challenge these findings? Do I go through the rehab facility where she is staying? The surgeon (who has been caring for my mother for related issues for a while)? The hospital, or the patient advocate who had been working with my mother while she was recovering from surgery?
Many thanks for any guidance!
Yes, definitely ask the rehab facility for help -- they want to get paid, and will be motivated to help you. This is totally normal and not a special request.
(I'm assuming you are in the US, if you aren't the following might not apply) In the mean time, for your peace of mind, be aware that it's ALSO normal for insurance to deny coverage and then to approve it on the second or third submission. Often it's a matter of paperwork and/or the order that things are submitted, but sadly it's sometimes a matter of policy (formal or informal) to deny the first submission.
posted by OrangeDisk at 6:24 AM on August 28, 2023 [5 favorites]
(I'm assuming you are in the US, if you aren't the following might not apply) In the mean time, for your peace of mind, be aware that it's ALSO normal for insurance to deny coverage and then to approve it on the second or third submission. Often it's a matter of paperwork and/or the order that things are submitted, but sadly it's sometimes a matter of policy (formal or informal) to deny the first submission.
posted by OrangeDisk at 6:24 AM on August 28, 2023 [5 favorites]
It's very possible there was a denial followed by an appeal that was approved, the mail may be an automatic thing that happened but it has already been fixed.
posted by AlexiaSky at 6:44 AM on August 28, 2023 [1 favorite]
posted by AlexiaSky at 6:44 AM on August 28, 2023 [1 favorite]
Does your mother have a managed Medicare plan? These are like the ones offered by Aetna/Anthem/Blue Cross etc. My dad has one of these and they are NOTORIOUS for being stingy with denying rehab coverage (NYT article on this topic), or only approving stays for a couple days at a time. My understanding is that original Medicare plans are much less weird about prior authorizations for rehab stays, and often cover several weeks at a time out of the gate.
Check with the hospital social worker - they're very skilled at helping educate you. I almost always appeal these kinds of things primarily out of spite (there is a process you should be able to follow for this), like my own personal middle finger to the insurer. I have only rarely won an appeal, but it does happen occasionally.
posted by mostly vowels at 6:59 AM on August 28, 2023 [3 favorites]
Check with the hospital social worker - they're very skilled at helping educate you. I almost always appeal these kinds of things primarily out of spite (there is a process you should be able to follow for this), like my own personal middle finger to the insurer. I have only rarely won an appeal, but it does happen occasionally.
posted by mostly vowels at 6:59 AM on August 28, 2023 [3 favorites]
If you haven’t already, definitely get in touch with the rehab’s social worker. They can point you to the right people to deal with the insurance/financial side, but will also help manage her treatment and figure out post-rehab plans.
I’m guessing the hospital’s advocate or social worker will be of limited help now that she’s no longer there.
If it’s financially feasible you could also consider privately hiring an elder care manager (other search terms: aging life care, geriatric care). It sounds like there’s going to be a lot to navigate going forward, and having someone who knows the system to provide guidance and deal with logistics on your behalf can be tremendously helpful.
posted by staggernation at 7:02 AM on August 28, 2023
I’m guessing the hospital’s advocate or social worker will be of limited help now that she’s no longer there.
If it’s financially feasible you could also consider privately hiring an elder care manager (other search terms: aging life care, geriatric care). It sounds like there’s going to be a lot to navigate going forward, and having someone who knows the system to provide guidance and deal with logistics on your behalf can be tremendously helpful.
posted by staggernation at 7:02 AM on August 28, 2023
Is this denial from a private insurer, rather than Medicare?
I have no idea if this is relevant, but in talking to my mother regarding her knee replacement and subsequent therapy, apparently her private insurer requires that any treatment that is plausibly covered by Medicare be submitted to Medicare first, denied by Medicare, then submitted to the insurer. When the doctor submitted directly to the insurer first (since my mother doesn't have the relevant Medicare coverage), the insurer denied the claim, but after submitting to (and getting a denial from) Medicare, the doctor's office was able to re-submit to the insurer, who then approved it. I assume the insurer just doesn't trust the patient and doctor's office to accurately understand the Medicare system well enough to accurately determine coverage.
As far as next steps, I think your first stop is probably the rehab facility. They will have lots of experience in dealing with this, and can probably help determine who else you should talk to and in what sequence. They may have even done a pre-admittance assessment of your mother's case, to determine if they think that she will be eligible for Medicare payment, and accepted her into the facility based on that, so they have an interest in helping you get the Medicare payment approved.
posted by yuwtze at 7:10 AM on August 28, 2023 [6 favorites]
I have no idea if this is relevant, but in talking to my mother regarding her knee replacement and subsequent therapy, apparently her private insurer requires that any treatment that is plausibly covered by Medicare be submitted to Medicare first, denied by Medicare, then submitted to the insurer. When the doctor submitted directly to the insurer first (since my mother doesn't have the relevant Medicare coverage), the insurer denied the claim, but after submitting to (and getting a denial from) Medicare, the doctor's office was able to re-submit to the insurer, who then approved it. I assume the insurer just doesn't trust the patient and doctor's office to accurately understand the Medicare system well enough to accurately determine coverage.
As far as next steps, I think your first stop is probably the rehab facility. They will have lots of experience in dealing with this, and can probably help determine who else you should talk to and in what sequence. They may have even done a pre-admittance assessment of your mother's case, to determine if they think that she will be eligible for Medicare payment, and accepted her into the facility based on that, so they have an interest in helping you get the Medicare payment approved.
posted by yuwtze at 7:10 AM on August 28, 2023 [6 favorites]
Assuming you are in the US and she is on Medicare, you should have gotten info in the rejection letter to appeal. Know that most Medicare HMOs make their money by rejecting claims like mostly vowels says. When my mom was in PT/OT rehab, I was calling in appeals every four days until we switched her to primary Medicare. At that point, it was all much smoother sailing.
The thing I wish someone had told up before was that Medicare HMOs greatly restrict the providers and facilities you can go to, and in this case, this meant my mom ended up in a pretty lousy facility. You never know how something like this would have worked out in different circumstances, but part of me believes that she wouldn't be as wheelchair dependent if she had landed in a better rehab facility.
posted by advicepig at 7:11 AM on August 28, 2023 [1 favorite]
The thing I wish someone had told up before was that Medicare HMOs greatly restrict the providers and facilities you can go to, and in this case, this meant my mom ended up in a pretty lousy facility. You never know how something like this would have worked out in different circumstances, but part of me believes that she wouldn't be as wheelchair dependent if she had landed in a better rehab facility.
posted by advicepig at 7:11 AM on August 28, 2023 [1 favorite]
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It might also be helpful to know your mother's insurer and where you live.
posted by Winnie the Proust at 6:14 AM on August 28, 2023 [11 favorites]