Hi Everyone,
As you know Friday we received a call from our primary insurance stating they were unsure about approving additional visits. Our policy allows for 60 PT/OT/ST sessions combined as a LIFETIME benefit. Not annual, LIFETIME. The insurance company was not convinced I understood the limitations associated with a Lifetime benefit and felt it was in our best interest that they judiciously administer the benefit disregarding the facts documented weekly that justified approvals. We have 9 visits left and then Corey’s secondary insurance will act as primary. She will then receive 24 visits per discipline as long as she shows functional improvement. Her secondary is more familiar with Neuro Out Patient documentation and we received the 24 session cycle for the first year of out-patient.
After our conference call on Thursday, our horrific week with Corrine and the pending decision call at 2pm on Friday I came as close as I’ve come to a nervous breakdown since the last few months of our inpatient days. Our case manager at Bryn Mawr is new to her position but very good. She was the messenger at 2pm. I asked her to call the insurance company’s clinical manager and leave a message that we would be driving one hour in one direction on Monday. We insist on a decision Monday morning because we will be having PT at 2pm. If we do not receive the final 9 visits, the mother of their client has requested a conference call with her and her supervisor at 12 noon.
I turned off the phones and the internet, escaped Saturday and prepared our argument with statistical information on Sunday.
We arrived today for Speech *as planned and coverage was previously approved.
At 11:50, our case manager knocked on Kate’s door. I excused myself and joined her.
CM-Did you call anyone at the insurance company?
M-No, I was waiting until today
CM-you swear you didn’t call anyone
M-No! We’re going to call them after Speech, did you hear from them
The case manager handed me a faxed form…all 9 visits were approved!
CM-what the heck happened? She said on Friday she wouldn’t approve all 9. She has been giving us a hard time for weeks!
M-All I can tell you is I put it out on the CarePage and asked for prayers…it’s divine intervention!
CM-it has to be because this woman was not giving an inch. She gave us a hard time as if it was a personal vendetta
Natalie and Elaine walked by as Corey joined us. They were giddy with excitement that we won.
Corey looked at them and said, “They are afraid of Marie, she wears them down”…we all laughed
Thank you for all your prayers; guess I can tell the flying monkeys to stand down now!
I had a physical wave of relief come over my body. I was not aware of the magnitude of the stress that had built up in my chest.
This brings me to a very important lesson. If we can teach you anything from our journey please learn this. Please read your healthcare policy. Check length of stay as an inpatient, rehabilitation coverage as inpatient and outpatient and your home, health and hospice coverage. Most people look at their deductibles for pharmacy and if they need referrals for specialists. There is much more to consider. Our circumstance could happen to anyone of you. Accidents happen. Please look into your total coverage.
In addition, if you have a child under the age of 18, please discuss what would happen if they are in an accident. It’s a difficult conversation to have but if it happens, you as a parent and/or sibling will have no legal rights to any health or financial decisions on behalf of that child once they turn 18. A simple statement of who they would like to make medical decisions on their behalf, signed and notarized by you both will protect you if an accident happens. Otherwise, you have to go to court to fight for guardianship to protect your child from the “state” making decisions for them. This is an important document for spouses or significant others as well. Protect your right to advocate for your loved one!
Finally, don’t be afraid to fight. It’s exhausting but no does not mean no. There are several levels for appeal that are all within your rights. The policies don’t point out your advocacy rights but they do exist as you all have seen. Never give up and never give in and NEVER take NO from someone that can’t say YES!
On to a happier note and speaking of YES….our family is very excited to announce that JohnPaul proposed to Jackie and she said YES! Every day is a new day filled with reasons to keep looking forward Corey’s new PT goal…to walk down the aisle for JohnPaul and Jackie’s wedding without a walker! She also wants to dance with her brother at the reception. We’ve got a lot of work to do to achieve that and we will continue to fight everyday to make sure we do! xoxo