Health Insurance Denied

ReadMe079

My sister (who is now deceased) was recently sent to a skilled nursing rehab facility after a fall that left her non-ambulatory. Her health insurance pre-approval was denied, and after 2 appeals on my part, I have been told by the rehab facility that the reason for denial was because she had Alzheimers. The insurance company does not come out and say this, but I was told by an administrator at the rehab facility that this is rather common. I am trying to find an attorney that can help me, but would like to know if others have experienced this issue. This seems like blatant discrimination to those suffering from dementia, and it makes me sad that those without someone to advocate for them have to just accept this.

Marta

To clarify: was your loved one admitted to rehab for a time, then at some point insurance denied ongoing care?

ReadMe079

Marta, Her pre-approval was denied by the insurance company. I've been told that if the pre-approval is denied by the insurance company and the patient receives services from the facility despite the denial of pre-approval, the pre-approval can no longer be appealed. The rehab facility said that once the pre-approval is denied by the insurance company, that they no longer keep detailed records, such as coding, needed to submit a claim to the insurance company. When I went back and spoke to the insurance company, they told me that the rehab facility must submit the claim (it would be for room and board, since the facility billed the insurance company for PT and OT and the claims were paid by the insurance company), but the rehab facility refuses to submit a claim. I am weighing my options at this point.

Marta

This is no consolation, but in general the prevailing attitude in the insurance industry seems to be that people with dementia can benefit only minimally from rehab because of their memory deficits.

I’m so sorry for the loss of your sister, and that she didn’t receive the care she deserves, that we all deserve.

ReadMe079

Thank you for your kind words. I agree with your assessment regarding the insurance industry. It's hard to believe that they can get away with this. I'm not done fighting however, and I feel sad for those suffering with dementia that don't have someone to advocate for them. Just to be clear, she did receive PT and OT for 2 weeks, but the insurance company is not covering her room and board for that period of time.

Marta

So because the pre-approval was denied, which likely you weren’t told about, your sister had two weeks of therapy for which insurance coverage was denied? I’m so sorry, so unfair!

[Deleted User]

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Quilting brings calm

I am trying to figure out what was paid and what wasn’t? Did the insurance pre-approve the therapy but not the need to be in rehab for it?

Was the insurance a private insurance company? Medicare Advantage? Medicare plus a supplement? Was your sister actually admitted to the hospital for 3 days prior going to rehab? Or was she just in the hospital for observation?

If she was only in the hospital under observation status, you might start there. If you can retroactively get that changed, then the rehab could rebill. They know the services they provided because they billed for them and the billing system still has it. They can’t expect you to pay them if they can’t itemize the charges. it’s a matter of reassigning codes to services.

You could also go to your state’s agencies that handle complaints about insurance, hospitals and facilities.

ReadMe079

My sister was sent to the hospital after a fall at the MC facility and X-rays showed no broken bones. She was released next day and sent back to the MC facility. It became obvious that she was no longer ambulatory, and the MC center is not staffed or licensed ny NYS to care for patients that are non-ambulatory. They sent her to a SNF for rehab. Both the hospital and the PT evaluation recommended that she receive PT for rehab. I have both the hospital and PT notes. She was taken to SNF that is a under the same umbrella that the MC facility is under, and the same day that she arrived, the insurance company responded with a letter denying her pre-approval. The reasons given were all untrue, and I have documentation to refute them as well. There was one statement in that letter stating that states "you were not able to and declined to participate in therapy due to your chronic health decline." She never declined therapy at the MC center or refused to participate,(again, I have documentation) but the phrase "chronic health decline" seems to mean that she had dementia, so they are not going to pay for her room and board, while she is at the SNF, as there is little chance that rehab would be beneficial. The facility did provide daily PT and OT for 2 weeks, and the facility billed the insurance company and the claims were paid. Claims were also paid for in house doctor or NP visits, X-rays, and medications. This is a medicare advantage plan through Excellus BCBS. I did not sign a declaration of self pay. I have engaged a lawyer who is working with me but his initial suggestion is that I try to negotiate with the SNF, which was in the works, but I have not gotten a call back from the person in finance at the SNF. She was supposed to get back to me on February 10, and after not hearing from her, I have made 2 calls to her with no call backs. I have reached out to an attorney who is researching my responsibilities and options. There is more to this story but as Marta responded above , it is clear that the insurance industry does not want to pay for those with dementia to try to rehab. Its amazing to me that they are allowed to get away with this. I think I will also reach out to my NYS attorney general and file a complaint. This is an example of why medicare advantage plans are not the way to go for those with chronic or severe health issues. By the way, I did appeal this denial twice, to no avail.

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