What does the denial letter specifically say? Does she not have Medicare as a secondary insurance? The admissions coordinator, financial counselor, social worker, or even discharge planner might have some input and help into this. Documentation needs to be clear that this wa an acute deterioration of her level of function.
Aetna - like other for-profit insurers - does not stay in business by paying for medical care; they stay in business by collecting premiums and weaseling out of providing medical care. That said, unless they specifically exclude the service, they may be required to cover it. Your physicians and maybe the state insurance commission could be allies in this battle.
Robin, if she cannot or will not participate in PT, she either goes home or goes to long term care. Talk to the discharge coordinator AND the social worker.
Hi Rockin - The Aetna denial letter must give the specific reason/exclusion quote from her Evidence of Coverage. Depending on where you live, you may have 2 more appeals coming. The 3rd appeal is usually sent out to an External Review Board. I don't know if her Aetna plan is an HMO or PPO. They are governed by two different entities. The basis of your appeal should use the phrase "MEDICAL NECESSITY". You must show that her rehab is medically necessary for her cure and without the rehab, her condition will deteriorate thus leading to further medical complications. Pull out her Evidence of Coverage and pour over the list of Exclusions. It will give you ideas of words to Stay Away from.
Robin - I'm so sorry about the sepsis dx. I hope, by now, you have an update on her condition and prognosis. You indicated that this might be more of an insurance (Aetna) issue? She must have had a doc's order to go to rehab and rehab doesn't 'kick you out' unless you can't/won't participate in their care plan. Most of us are used to dealing with Medicare, which doesn't require Prior Authorization for such things. Maybe Aetna was lagging on the Prior Auth? Pls keep us posted on the situation.
Thank you all for your advise . Right now I am waiting for the rehab to get me all the information in ref to her care plan then I am going to apeal her case one more time. Any advise on what say would be greatly appreciated.
Have you thought about obtaining Medicare as your mother’s primary coverage? From the description of the problems Aetna is creating, I think you’d be a lot happier with Medicare. And at 78, your mother is certainly eligible. I think I'd start working on that right away.
Also, does your doctor have any recommendations, even if he won't get involved? Could he write a new script for rehab for the various issues that have arisen since she was discharged from the hospital?
Is your mother seeing any of her regular doctors who might be treating her in the rehab facility?
I believe someone asked about the specific reason for the denial. What was the justification Aetna claimed for denying further coverage, if that's the position they took? Knowing that might help others offer suggestions.
There might be some ombudsperson agencies in the area that could help or offer guidance as well. Try Googling that subject to see what you get. During our first experience with a skilled nursing facility for rehab after Mom broke her leg, we had some problems with them and I looked for and found a few local ombudsperson agencies that were very helpful in giving me advice.
Your local Area Agency on Aging likely would also have contact information for these kinds of agencies.
Another option is to call your local county bar association and ask for a list of lawyers who handle denials of coverage (or whatever Aetna called their position), then contact them and see if you can get a free 1 hour consultation, which some of them offer.
Some law schools have free legal clinics; that's something to check out as well. You could get legal advice on how to proceed.
Some senior centers and/or local municipalities have "consult an attorney" nights weekly, biweekly, or less frequently. You won't get a full consultation but you might be able to get some clues on other ways to deal with Aetna.
Lastly, call a local state congressperson or state rep - sometimes they have people on staff who can offer some guidance, although I doubt they would actually become involved in the appeal.
Debdaughter - I think it entirely depends on how you leave a company. The people who retire where I work can keep the employer coverage by paying the COBRA fee, which is astronomical but better than nothing.
There should be a section in the Evidence of Coverage (EoC) with instruction on how to file an appeal, time constraints, etc. Sometimes an appeal is referred to as 'Grievance'. The 3rd party External Review Board should consist of an attorney and a physician that holds a specialty in the type of medical need being denied.
Could it be that the doctor and the facility don't really think Mom would benefit from an extended stay, and that is why they are standing back? If that might be the case, it would be good to know what they think would be best for her.
Thank you everyone for all your advise. I just want to clarify a few things the doctor and the rehab both agree that she needs to stay at the rehab.....As I stated in the beginning my mother was working and independent before all this happened the physical therapist said he never saw anyone work as hard as mother. I will take all your advise and handle this appeal thanks again to all of you that took your time to really care and understand.
Aetna - like other for-profit insurers - does not stay in business by paying for medical care; they stay in business by collecting premiums and weaseling out of providing medical care. That said, unless they specifically exclude the service, they may be required to cover it. Your physicians and maybe the state insurance commission could be allies in this battle.
Have you thought about obtaining Medicare as your mother’s primary coverage? From the description of the problems Aetna is creating, I think you’d be a lot happier with Medicare. And at 78, your mother is certainly eligible. I think I'd start working on that right away.
Also, does your doctor have any recommendations, even if he won't get involved? Could he write a new script for rehab for the various issues that have arisen since she was discharged from the hospital?
Is your mother seeing any of her regular doctors who might be treating her in the rehab facility?
I believe someone asked about the specific reason for the denial. What was the justification Aetna claimed for denying further coverage, if that's the position they took? Knowing that might help others offer suggestions.
There might be some ombudsperson agencies in the area that could help or offer guidance as well. Try Googling that subject to see what you get. During our first experience with a skilled nursing facility for rehab after Mom broke her leg, we had some problems with them and I looked for and found a few local ombudsperson agencies that were very helpful in giving me advice.
Your local Area Agency on Aging likely would also have contact information for these kinds of agencies.
Another option is to call your local county bar association and ask for a list of lawyers who handle denials of coverage (or whatever Aetna called their position), then contact them and see if you can get a free 1 hour consultation, which some of them offer.
Some law schools have free legal clinics; that's something to check out as well. You could get legal advice on how to proceed.
Some senior centers and/or local municipalities have "consult an attorney" nights weekly, biweekly, or less frequently. You won't get a full consultation but you might be able to get some clues on other ways to deal with Aetna.
Lastly, call a local state congressperson or state rep - sometimes they have people on staff who can offer some guidance, although I doubt they would actually become involved in the appeal.
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