Reply To: Insurance Question

February 20, 2014 at 3:55 am

Thanks for all of the responses. I have been advocating for my wife from day one, spending hours a day with her in the hospital, every day, working with all of her caregivers. Everyone in all of the facilities she’s been in knew me very well. 🙂 On January 24th, she did move to an SNF to continue her rehabilitation.

Unfortunately, after three weeks, I’m having to fight a battle now with my health insurance provider for her continued coverage at the SNF. I learned this past Friday from my insurance Case Manager that they would no longer be certifying her stay at the SNF beyond this past Monday because they didn’t feel she was making enough progress to continue the level of care she’s currently receiving. It’s complete nonsense. When my wife was transferred to the SNF, she could barely lift her arms off the bed and had very little movement in her legs. Her arms have gotten much stronger and this past weekend she was actually able to give our son a hug for the first time in over three months. She’s also showing a lot more movement with her legs, but she still needs complete care because she’s still not able to stand and has no functional use of her hands. There’s a lot more rehab that needs to be done and even though she’s showing improvements, insurance feels that because over a three week period she still is at a level of needing complete care, that she’s not meeting the criteria for the care she’s receiving. So, over the past few days, I’ve been really scrambling trying get things sorted out. On Friday, after I found out about the denial of coverage, I filed an expedited appeal with my insurance which was promptly denied on Saturday. So, I thought I had two more appeals based on what my Case Manager told me, but found out on Monday that I only had one more, which is an external review. My wife’s doctor, therapists and social worker at the SNF have really been going to bat for her and have put together a lot of documentation that hopefully will show that she really needs the care she’s getting now. I reached out to my employers HR dept. and spoke with an Advocacy Support specialist to see if they could assist me in any way. Nope, they can’t override Aetna’s decision and the only thing they could suggest was for me to seek legal advice. So, at this point, I’ve submitted an application for Medicaid. From conversations with management at the nursing facility, it should not be an issue getting my wife approved. The nursing facility is willing to keep her there until her Medicaid goes through, then retroactively bill Medicaid for her stay. But, Medicaid will not cover her meds and rehab. My hope is that the external review works out for us. And if Medicaid for whatever reason doesn’t come through, I’m not sure what I’m gonna do yet. I may not have a choice but to consult an attorney.