The insurance co. wants to kick my Mom out of the rehab. What do I do?

Robin, they sent your mom to rehab with her not being able to walk?

thank you, sandwich, think that's what I'd thought too; just like when you get laid off - don't think I've ever known too many people who could afford COBRA; maybe in a way she's blessed but then on the other hand, with what she's going through I wonder

Thank you everyone for all your advise. I just want to clarify a few things the doctor and the rehab both agree that she needs to stay at the rehab.....As I stated in the beginning my mother was working and independent before all this happened the physical therapist said he never saw anyone work as hard as mother. I will take all your advise and handle this appeal thanks again to all of you that took your time to really care and understand.

Debdaughter - I think it entirely depends on how you leave a company. The people who retire where I work can keep the employer coverage by paying the COBRA fee, which is astronomical but better than nothing.

thanks, garden, wish she'd posted that here, wonder how things are going now; seems that's what happens - but also think this is the very reason why Medicare was started

Deb, this was on Robin's message board:

Rockinrobin1204 posted 5/13/2015 at 7:23 pm

"Thank you everyone for your feedback on my mom just clarify some info my mom is 78 still works she is doing everything she is suppose to do"

I interpreted that as that her mother is actually still working for an employer.

I didn't get the idea mom was still working, just that her insurance was from the job she'd had - not sure I realized you could still keep your employer insurance or at least didn't think most people did - maybe this is why? any more insight on this as we're looking down the road

Rehab is supposed to be temporary. Nobody is going to stay in rehab until they are completely well because that isn't the point of rehab. If you aren't getting better and can't meet the care goals within those first 3 weeks or so, you have to go into another care facility to be taken care of. If you are getting better and meet the goals, then you have to go back to where you were living before.

There should be a social worker at the rehab place or the head nurse who can explain the goals to you, what is being to done to help mom reach the goals (the therapies), and how she is progressing (or not). At some point, they stay there does have to end whether mom is well or not.

For example, my mom was in rehab twice after two different hospitalizations. After about a week, she refused to do the PT activities. They can't force her to.
So after a generous period of pleading, cajoling, and bribing her, she still refused so they had to move her on out. She couldn't stay there indefinitely and occupy a high-demand bed. So she went into a skilled nursing unit/dementia unit where they continued trying to get her to do PT.

Jeanne - I agree. It's looking like the doctor and facility think the Appeal lacks merit.
Rockin - I'm not saying it does; but it would explain their lack of cooperation. Good luck.

I missed this the first time I read your profile but now realize that your mother is still working. Have you contacted the HR department of her employer to ask for assistance? If she's off on short or long term disability, it's in their best interests to have her back on the job sooner rather than later, so they have a vested interest in her successful recovery.

Robin,

Have you thought about obtaining Medicare as your mother’s primary coverage? From the description of the problems Aetna is creating, I think you’d be a lot happier with Medicare. And at 78, your mother is certainly eligible. I think I'd start working on that right away.

Also, does your doctor have any recommendations, even if he won't get involved? Could he write a new script for rehab for the various issues that have arisen since she was discharged from the hospital?

Is your mother seeing any of her regular doctors who might be treating her in the rehab facility?

I believe someone asked about the specific reason for the denial. What was the justification Aetna claimed for denying further coverage, if that's the position they took? Knowing that might help others offer suggestions.

There might be some ombudsperson agencies in the area that could help or offer guidance as well. Try Googling that subject to see what you get. During our first experience with a skilled nursing facility for rehab after Mom broke her leg, we had some problems with them and I looked for and found a few local ombudsperson agencies that were very helpful in giving me advice.

Your local Area Agency on Aging likely would also have contact information for these kinds of agencies.

Another option is to call your local county bar association and ask for a list of lawyers who handle denials of coverage (or whatever Aetna called their position), then contact them and see if you can get a free 1 hour consultation, which some of them offer.

Some law schools have free legal clinics; that's something to check out as well. You could get legal advice on how to proceed.

Some senior centers and/or local municipalities have "consult an attorney" nights weekly, biweekly, or less frequently. You won't get a full consultation but you might be able to get some clues on other ways to deal with Aetna.

Lastly, call a local state congressperson or state rep - sometimes they have people on staff who can offer some guidance, although I doubt they would actually become involved in the appeal.

Could it be that the doctor and the facility don't really think Mom would benefit from an extended stay, and that is why they are standing back? If that might be the case, it would be good to know what they think would be best for her.

Hi Rockin - I don't know how your mom's Aetna plan works, but under Medicare; you can certainly appeal a discharge, but if you lose - you get stuck with the bill for the additional days in the facility. That's why, if at all possible, a Medicare discharge appeal is usually started a few days before the discharge date to allow time for review. Has anyone from Aetna talked to you about this? What was the discharge date that you are Appealing?

I have never been so frustrated I can't get anyone to help me with this appeal I have asked the social worker to help and she said they don't get involved. I have requested all my mom's records so I can see what the prognosis and I am still waiting. It's just so sad

She still in the rehab I think they are waiting for me to do the next appeal

Where is mom? Did you take her home or did she go to long term care?

Unfortionately no one is working with me including the social worker from the re hab

Alas, I can sympathize with men and women who studied years to practice medicine now being expected to deal with dozens of different insurance companies with slightly different rules and coverages. I know a doctor who actually got so tired of it he gave up his practice. And the administrative side of clinical medicine is a huge reason our costs are so high. So I hardly blame the doctor for not getting involved, but it puts a burden on you, and I'm sorry about that.

Good luck, and do keep us informed.

There should be a section in the Evidence of Coverage (EoC) with instruction on how to file an appeal, time constraints, etc. Sometimes an appeal is referred to as 'Grievance'. The 3rd party External Review Board should consist of an attorney and a physician that holds a specialty in the type of medical need being denied.

Is the FACILITY working with you to appeal to the insurance company?

Thank you both for your advise I did ask her doctor to help but he said he doesn't get involved with insurance company's.

Anytime I have had to appeal something with an insurance company the doctor who feels the service or product is beneficial or necessary has written the appeal letter. Have you discussed this with her doctor?

It is hard to know what you should write without knowing the reason for the denial.

One doctor who was very experienced with appeal letters always emphasized that it would save money in the long run, because without this item deterioration was more likely and faster and would cost more to treat, or something like that. I can't tell you we won every appeal, but most of them were successful.

If you can share the detailed of the denial, perhaps someone can give more specific advice.

Hi Rockin - The Aetna denial letter must give the specific reason/exclusion quote from her Evidence of Coverage. Depending on where you live, you may have 2 more appeals coming. The 3rd appeal is usually sent out to an External Review Board. I don't know if her Aetna plan is an HMO or PPO. They are governed by two different entities. The basis of your appeal should use the phrase "MEDICAL NECESSITY". You must show that her rehab is medically necessary for her cure and without the rehab, her condition will deteriorate thus leading to further medical complications. Pull out her Evidence of Coverage and pour over the list of Exclusions. It will give you ideas of words to Stay Away from.

Thank you all for your advise . Right now I am waiting for the rehab to get me all the information in ref to her care plan then I am going to apeal her case one more time. Any advise on what say would be greatly appreciated.

Medicare will cover 100% of the cost for day 1-20, after that she would have a copay. It depends on what her insurance will cover. I'd have her reevaluated and ask for a care plan to come up with a solution for her to improve before going home. You can also contact your local long term care ombudsman who is an advocate for residents in facilities.

Rockinrobin, how are things going?

What does the denial letter specifically say? Does she not have Medicare as a secondary insurance? The admissions coordinator, financial counselor, social worker, or even discharge planner might have some input and help into this. Documentation needs to be clear that this wa an acute deterioration of her level of function.

Aetna - like other for-profit insurers - does not stay in business by paying for medical care; they stay in business by collecting premiums and weaseling out of providing medical care. That said, unless they specifically exclude the service, they may be required to cover it. Your physicians and maybe the state insurance commission could be allies in this battle.

Hi I did an appeal but Aetna turned us down I am not sure what to do next. I just don't understand how they can refuse her coverage when she can not get up and go to the bathroom on her own. She was a independent 78 year old women who was able to take care of herself. I am not sure where to turn for assistance

Robin - I'm so sorry about the sepsis dx. I hope, by now, you have an update on her condition and prognosis. You indicated that this might be more of an insurance (Aetna) issue? She must have had a doc's order to go to rehab and rehab doesn't 'kick you out' unless you can't/won't participate in their care plan. Most of us are used to dealing with Medicare, which doesn't require Prior Authorization for such things. Maybe Aetna was lagging on the Prior Auth? Pls keep us posted on the situation.

Robin, if she cannot or will not participate in PT, she either goes home or goes to long term care. Talk to the discharge coordinator AND the social worker.