The following is a brief overview that represents the motivation behind why we must work with the Senate and Congress to fight for legislative changes that hopefully affect Insurance coverage.
Yesterday I shared that not only were we being discharged from the current therapy agency due to license restrictions, we were also informed that our primary insurance had denied the next certification period that we were using to transition to the next step for Corey. The appeal was entered and we were told that services should continue until the case was evaluated and the appeals were exhausted.
Today I entered the ring at 9:30am. I was already on duty as we had no nursing overage today. The bell rang and for the next 6 ½ hours I had my advocate gloves on as I also tried to give nursing care to Corey. I received a phone call explaining that although Corey’s insurance denial was in the appeal stage, the agency would not send their therapists out. If the therapists were to continue services and we lost the appeal, the agency would not be paid and could not collect for services rendered. Therefore, without an authorization from the insurance company I would have to give them a credit card if I wanted Corey to have therapy while her case was in appeal.
Round 2 – Dr. B entered the ring. She placed a call on Corey’s behalf to the Medical Director. After she insisted on a peer to peer review, she was denied. She refused to take NO for an answer and composed a letter faxed to appeal the Medical Director’s decision.
Round 3 – Simultaneously to Dr. B’s call I placed a call to our Insurance Case Manager. Normally I get a voice mail; today he answered the phone on the first ring! Fortunately he has been working closely with his manager and she in turn has been working with her manager. We had a conference call to discuss how insurance could deny all services within a 24 hour period without notification. We spent almost an hour on the phone as I pleaded Corey’s case. We discussed her progress, goals and reason why therapy can not be terminated at this time. PT/OT/ST is as critical to her daily regime as her seizure medication is. Removing them would be the same as discontinuing all her medications. The case manager and supervisors were extremely helpful, patient and willing to step into the ring with me.
Round 4 – I reached out to the Brain Injury Association of PA. Our discussion led to information that could help my appeal. I called Insurance back and asked if the Medical Director was a Physiatrist, a neurologist or had a CBIS (certified brain injury specialist) certification? Did they understand that a TBI was not a broken bone and denying services while the appeal was “up in the air” would set her progress back. The Insurance case managers were extremely helpful. They actually went to the Medical Director with my plea, details of Corey’s progress and looked into whether or not the Director had a thorough understanding of the complexities of Corey’s injury. The case went up to the Regional Director and I was asked to sit tight.
Round 5 – “sit tight”…two words that are not in my vocabulary. The vision I have that best describes what this time felt like for me would be to imagine a caged tiger pacing in her cage. Instead of pacing I clean; dust, vacuum and do laundry, as I replay the details of each conversation hoping I didn’t forget anything. “Sit tight” to me means keeping my mind busy wondering what else I can do before the close of the business day and begin thinking of tomorrows strategy. Fortunately Corey was taking her afternoon nap so I had quiet time to think and busy work to help me pace.
The bell rang…I answered the phone. The case supervisor called to let me know that the insurance company extended coverage for therapy for the next four weeks! They would be calling Dr. B and the agency to inform them directly.
Our story is not special. It represents the struggle thousands of families across the country have daily. We happen to receive good news today, but that’s not always the case for us and for most families. My sister forwarded a facebook post that best summarized the moral of today’s story;
1. If you do not go after what you want you’ll never have it.
2. If you do not ask the answer will always be NO.
3. If you do not step forward you’ll always be in the same place.
Corey we live by these three simple rules. It is precisely why you are making such tremendous strides. We never give up and never give in; especially when we feel like we’ve been knocked down and can’t find the strength to get up. The next four weeks will be very challenging but the good news is, we have our team in place to continue working towards the next step forward. Rest well, we’ve got work to do, xoxo