The Games Insurance Plays

Mom fell and broke her arm in August. For her, this is yet another setback with its own complicated set of hurdles. The effects of tardive dyskinesia in full effect, she now has two disabled arms and can do little for herself.

Things we take for granted when we are young and able bodied, become mountains for many as they age. Getting dressed, feeding oneself, bathing, using the restroom, even standing up.

Everyone agreed she needed to go to rehab for therapy

In the beginning of September mom’s care team at the assisted living facility called a care conference where everyone assembled to discuss mom’s case.

Physical therapists, nurses, the nurse practitioner, the facility director, the director of nursing, the only folks who were not in attendance were the actual aids that perform much of the heavy lifting.

The consensus amongst the group was that mom had a qualifying hospital stay from her broken arm and was in need of therapies, more than what could be offered at assisted living. Mom was in a state of physical decline, and if it continued, there was a real risk mom would not be able to regain some of these skills.

At the outset, the expectation was mom would require close to a month long stay at the rehab facility.

Almost two weeks later…

After waiting patiently for two weeks, a rehab facility was able to admit mom for rehab and therapy.

The report from the therapists and nurses was that mom was engaged in all of her therapies and they were already beginning to see gains. Mom was doing the assigned “homework” that the therapists gave her each day. In short, there was clear clinical benefits from the rehab and therapies.

An unceremonious discharge

Eight days into mom’s stay, she received a two page notice of discharge:

The above is the notice mom received.

The social worker at the Laurels immediately called QIO LIVANTA, a third party entity that makes decisions on appeals filed by members regarding coverage. The Laurels notified QIO LIVANTA that we were appealing this decision. That was on a Friday, September 23rd.

When you call the number listed on this notice of non-coverage, it takes you to a voicemail box. You leave a message, you request a call back. No one called back on Friday. No one called back on Saturday. No one called back on Sunday. On Monday by 3pm, still there was no word from QIO LIVANTA.

The Laurels indicated that mom had to be discharged because there was no coverage to continue her stay.

It was clear she couldn’t go back to assisted living.

Monday afternoon I went over to the Laurels to see mom and talk to the staff. From seeing mom it was clear that she had some improvements, but wasn’t ready to leave, she needed to be there. I called QIO LIVANTA and I too was routed to the black hole of its voicemail.

Frustrated, I called the Aetna Medicare plan that mom is a member in. Aetna said it can’t help, and transferred me to State Teachers Retirement System (STRS) to speak to one of its representatives.

STRS was less than helpful

I was connected with Alexis at STRS who immediately threw up a hurdle of not being able to talk to me because I am not the member. I explained that I was mom’s legal guardian and I’d send her the letter of guardianship immediately via email or fax so we could get past this little issue.

Alexis then told me that she can’t talk to a guardian, she needs a “durable healthcare power of attorney.” Yeah, there’s no such thing in the state of Ohio. A guardian is someone who is appointed by a probate court to make healthcare decision on behalf of another – it trumps any power of attorney.

There is a such a thing as a healthcare power of attorney, but “durable” applies to financial power of attorneys, and if Alexis was up on Ohio law, she would know that all POAs signed after the adoption of the Uniform Power of Attorney Act is presumed durable – but again – healthcare power of attorneys are presumed durable because patients make their own decisions until they can’t.

After explaining this to Alexis, she let that issue go and then turned to “did you actually file an appeal?”

I told Alexis we’ve called QIO LIVANTA and left messages, but we haven’t heard back from it.

Alexis then asked,”but did you actually file an appeal?”

Again, I said both the facility, mom, and I had called QIO LIVANTA but we haven’t heard back.

Alexis then, quite unhelpfully noted, “but there is no appeal in the system and you had a two day window, did you file an appeal?”

Again, I said we called QIO LIVANTA and we haven’t heard anything.

Alexis then again started asking if we’ve filed an appeal.

At this point, I kind of lost my cool.

We were nearing the end of the business day

The Laurels indicated they would allow mom to stay, but without any coverage they needed guaranteed payment. Fortunately, the Laurels is staffed by human beings. I walked down to the business office, spoke with Anita for five minutes, and we agreed she’d send me a bill for any uncovered stay. I acknowledged that was okay with me and I clarified that I’d be looking at a rate of nearly $500.00 per day for the facility and therapies. Anita confirmed.

The next morning

The next morning I received a call from QIO LIVANTA, apologizing that they hadn’t called sooner. They received the request for an appeal and opened the file for review, collecting mom’s records for a physician to review and decide if mom’s stay was necessary.

The physician agreed, mom can’t be discharged and the stay is continuing to be covered for an unknown period of time.

What happens normally?

After this was sorted, I touched base with the facility social worker and asked what the normal flow was for this sort of thing. The social worker indicated that increasingly, this is becoming common place. The member files the appeal, the insurance company takes no action, and faced with possibly having to private pay, the patient leaves the facility. Once the patient leaves the facility the matter is closed as the appeal is then moot.

My mom was a teacher for 23 years before having to take disability retirement. She makes a modest amount of money on disability, around $2,000.00 per month. She receives no other income and we are covering the cost of her care from savings.

I have seen all sorts of holes in the health care system as I have been working as a part of it for over eighteen years now. The fact that insurance companies are essentially strong-arming patients out of necessary medical treatment and forcing them to return home and not receive the benefits of a plan they’ve been paying into for decades… it is bonkers.

How could this be better?

Insurance companies should not be able to terminate coverage if a patient communicates a desire to appeal a decision. From the moment the patient communicates a desire to appeal a decision of non-coverage until the appeal is heard, the insurance company should have to continue to be on the hook for coverage.

Further, decisions of whether or not therapies and rehab should continue should not be vested in the insurance company alone. A physician, who has taken some sort of Hippocratic oath, whose duty is to the patient, should be reviewing these decisions.

The fact a group as large as STRS is letting its members get treated this way… its shocking. No one should have to engage insurance companies in these sorts of games when we are talking about consequences of not being able to take care of oneself. Bonkers.