My father, 84, is recovering from intestinal surgery. His entire medical team has signed off on him needing acute inpatient rehabilitation. He is progressing everyday. Humana has denied it, we appealed. It was denied again. Humana then sent it to Maximus for a third part review, but didn’t include any of our notes in the appeal, so Maximus has sided with them. We are in the process of appealing that for an ALJ. We are worried that if we send him to a subacute nursing home, he’ll die. They look so depressing, and we know we can’t take care of him at his home as our mom is 76 and not in any condition to take on the work. Any advice, suggestions?
1. Perhaps the medical team, especially the higher ranking doctors, would provide specific justification for the rehab after reviewing the denials. In other words, refute the denial "justification" with medical advice, from real doctors, not the ones who work for the insurance companies, who just review and literally stamp "denied."
I encountered this once when a hospital overnighted Dad after having "overly infused" him (per the NP) after what was to be an "in and out" surgery, but decided to keep him overnight. Since he hadn't been admitted, the med costs were denied. I appealed, and appealed again after the second denial, keeping the hospital informed along the way. I used legal discovery tactics, creating interrogatories (legal questions) which I requested they address as to the basis for their denial. And I kept up the contact, letting them know I wasn't going to give up.
Insurance was Medicare with BCBSM as medigap coverage.
They never responded, but eventually the hospital gave up and we didn't pay for any of the costs.
2. This could be a real gamble: consult a medical malpractice attorney and ask for a review of documentation to determine if Humana and/or Maximus are creating a situation that could cause more physical damage than currently exists. I don't know (a) med mal laws as they might apply to institutions as opposed to providers, but the companies such as Humana are in fact providers, or facilitators of medical treatment.
Threatening to sue though is a really big gamble. An aggressive and skilled attorney, however, could know how to do this. You would have to pay a fee to the attorney though, but this kind of action could save you thousands of dollars.
Another factor, is that attorneys can leverage their time more effectively by going after medical providers directly for malpractice claims. I don't have any insight though as to medmal charges against insurance carriers as opposed to direct medical providers (hospitals, doctors, etc.)
3. I would start researching other medical providers, and change coverage as soon as it's possible.
4. Prepare your own appeal to Maximus, pointing out strongly that Maximus did NOT have the benefit of all the relevant information. This might give them a plausible excuse for reversing their decision, i.e., blame it on Humana.
5. If there's one lead doctor in the team, ask about a long term care specialty hospital. I don't know the qualifications, but it could be that some of his medical conditions prior to and/or post surgery would qualify him. My recollection, however, is that there's a limit that can be paid for by insurance; I ended up paying several thousand for my father's second long term care rehab, but it was worth every penny.
However, his physical recovery was limited b/c of nonrehab medical conditions: he was on a ventilator and the pulmonary conditions overrode everything else.
6. Long shot, perhaps: research and determine if there are nonprofit organizations focusing on the kind of medical conditions he had, and ask if they offer any assistance, financial or otherwise.
7. I'm not really comfortable with going public, but setting up a GoFundMe request might yield enough to support the rehab he needs. There certainly are enough people turning to this means for a lot of issues, not as legitimate as your father's is.
I hope you can get some support from the medical team, though. Good luck, and best wishes.
I would wonder if you can call Medicare and see if the care Dad needs is covered by them normally. If they say yes, then explain that Humana is turning it down. Medicare contracts out to these MAs. I would hope they can override their decisions.
If her does well in subacute, he can transfer to acute.
A friend did it recently. He needs to demonstrate to the therapists that he can cooperate and work hard at rehab.
You are afraid that “if we send him to a subacute nursing home, he’ll die. They look so depressing…”. No-one I have ever met really likes the look of nursing homes, but that doesn’t mean that the medical nursing care is inadequate. Perhaps all these doctors do know what they are doing – are you sure that you understand what they are saying? This must be upsetting your mother and your brothers, as well as your father. It would be a great shame if it isn’t the best thing for you to fight so hard about.
In this situation, one cannot judge a book by its cover.