Posted on 08/12/2020 3:51:20 PM PDT by AzNASCARfan
My Daughter got the call she had been waiting almost 7 years for, exactly a week before Easter and they had a donor match for my grand son who has waiting all his life for new intestines to be transplanted... at the same time, they did stomach, pancreas and liver too.
She was very apprehensive at the time, because coronavirus was into full swing by then, his transplant surgery was in Pittsburgh and they were very high risk there at the time. Everything went well and he has healed up very good...
About 6 weeks ago now, the hospital tried to transfer him back to his home hospital in Mesa to do his final rehab and get him ready to go home. They only did it this way because 2 years ago he had the same surgery that he rejected and when it was time for rehab, insurance denied it in Pittsburgh due to out of network and required they send him back here for it.
Fast forward and now Insurance denied it because we were having a new outbreak here in Arizona... They have not specifically said that but use the line he is not stable enough... Doctors and others at the hospital have said he is perfectly stable and they believe it is because of Covid. This has gone on for 6 weeks now with his doctors submitting paperwork to have him discharged over and over again.
He is doing so good, they even tried to send him directly home and let home health care take care of anything he might need... i.e. mostly for the tracheostomy now, because they said he would have to have somebody present and watching him while he slept too. My wife is there with him in Pittsburgh and doing most everything for him, including changing trach ties and even the trach tube now but Insurance is still over riding his doctors orders and they wont authorize his flight home.
Even though we really can't afford to hire a lawyer to go to battle for us, I am wondering if there is any legal recourse at all or if we are just completely at the mercy of his insurance company?? Will they be stuck there until this finally ends after the election??
Has there been an appeal filed by the head of contract to the insurance company? I don’t mean a phone call, but an official, written appeal. There is an appeal process and the insurance company has to tell you what it is when asked. There are deadlines to them, usually 30 or 45 days from the initial denial.
Patients have no rights unless they are in the country illegally
Spiritof Liberty is correct. File a written appeal quickly with documentation of doctor affirming stability.
Try insurance commissioner for your state. Reach out to congressman and senator for help.
Thank you, I am not sure actually. She started to file the appeal right after the first denial and the hospital advocate she was dealing with told her to hold off and they resubmitted the request going hospital to home instead of hospital to hospital because they said maybe that was the reason they were thinking he was not stable enough. I will ask though and pass your suggestion along.
Another great suggestion I had not considered, Thanks!
so if the insurance co is paying to keep him where he is, you need to think about the why. So the kid is immuno suppressed. He will need to be in a “bubble” where ever he is. COVID would kill him. That said if anyone who could be in his presence is recovered, that would not be an issue. Thus anyone whos healthy ie no comorbidities get infected beat it prove it and they become the interface for him and the world. Also installing a uv light filter on your heating/cooling system will be important for him, and will help everyone. He will be subject to lots of normal infections most of us don’t think about, like the flu and colds. ask the docs about vd3 supplements, zinc, b12 shots. While it sounds like quackery, VC in massive doses seems to help reduce inflammation. So ask a MD/nutritionist about vc supplements, also ask the transplant team.
good luck keep us informed. Remember the most important thing is his survival. everything else can be changed as events allow.
“Try insurance commissioner for your state. Reach out to congressman and senator for help.”
The insurance company didn’t say the patient couldn’t fly home. They said they wouldn’t pay for it. Different problem. If the patient is being denied access to the state, then that’s a problem with the state, not the insurance company.
“...Insurance is still over riding his doctors orders and they wont authorize his flight home.”
Again, the insurance company cannot override the doctors, and are not in a position to stop the flight. They are just not going to pay for the flight. If the patient’s guardians wish, they can set up the flight and send him home whenever the hospital can get him released....at their expense.
There’s more to this than is being told. What does it say in the policy they signed? That normally has a major bearing on these types of situations.
From the way this reads, call the senators and congressmen and ask them why the state or the doctors involved are refusing the flight? The insurance company has no say in it’s leaving. They are not part of the equation on the return. That plane can leave the runway whenever it’s ready with the patient aboard.
rwood
The problem is that unless you want to pick up the tab yourself, you are at the mercy of the insurance company. You can appeal the denial but by the time the appeal is heard the delay will be over.
Contact the adjuster and try to negotiate an earlier release. Get a written letter from the doctor agreeing that it would be not only safe, but better if he could return home. That might speed it up.
Good luck.
I don’t know all of the details but it sounds like they flew him (ins paid) to Pit to receive the transplant, seems like they could fly him home. He sounds like he would need medical attention in-flight.
Not knowing all details, my 1st thought (having been in insurance my entire career), was to get the ins. commissioner involved.
I would think a senator/congressman may know of some resources that could help financially, if the insurance doesn’t change their position.
Seems like the insurance company would think it might be wise to invest in a safe flight home after investing thousands of dollars in a transplant procedure.
Yeah that is part of the problem, When the first denial came, my daughter started looking into a non-profit medical flight to get him home and his advocate there at the hospital told her to definitely not go that route because if she did, the insurance company might cut off everything and not pay anything at all, including the hospital bill for the transplant and his hospital stay to date.
My main problem is just that insurance company keeps over riding his medical doctors orders and won’t give us any real reason other than he is not stable enough, when his doctors say he is. They even did a 3 way call with his advocate and hospital administrators talking to the insurance company doctors.
That is correct. Leaving Against Medical Advice has severe consequences. Beware of the hospital advocate — the only entity he or she has in mind is the hospital. Your best bet to understand the whys and wherefores of the insurance decision is the case manager.
You need to make sure you are in on the call. The adjuster will not have authority to override the utilization review alone but if you can get a supervisor involved and find some way to garner up some year jerking empathy, you might get somewhere. Insurance adjusters are trained to be rigid and emotionless, but most of them are mothers and will have a lot of empathy if you press their emotional buttons. Believe it or not they are human. They are just part of an inhuman system.
Don’t give up. But don’t lose your temper. Play on their emotions and try to get them on your side. They are trained to be heartless but they do have hearts. They can say no to a doctor a lot easier than they can to a mother.
Good luck.
Tear jerking. Typing on a phone is impossible.
I don’t know if you are shilling for the insurance companies, or just don’t know how things work. Getting Reglatory Affairs (through the Insurance Commissioner’s Office) or Legislative Affairs (through a Senatorial or Congressional) means that other eyes will be focused internally on the decision. It may not change the result, but it does mean that the bureaucratic obsticle will have to explain him or herself to an exec who might take other factors into consideration.
Then there is alway the abitious young reporter looking to stick it to the ‘man’. No execs like bad PR. And who knows-some billionaire might volunteer to loan a plane. A guy named Trump did that for a 3 yeaar old Jewish boy back when he had a real job.
And finally, if the patient is on Medicare, there are additional opportunities to trigger pain points for the insurer.
Or, of course, you could always cover the bill for the medical air transport if you don’t think the insurer should be bothered to re-visit their decision.
She did contact a couple reporters a couple weeks back, to see if there was any interest in doing a story on it. One of them had done a story about him and his short bowl syndrome about 4 years ago when we were waiting for a matching donor.
And Yes I think insurer is through medicare as he was considered disabled at birth and insurance is through his SSD
A lot of hospitals have a “patient advocate.” They have a level of authority in the hospital above the doctors, and are usually for making sure everybody at the Hospital is serving the patients appropriately. But if you tracked down the one there, they will usually have the ability and the motivation to find out just about anything medical related.
Be sure to send a letter to their boss saying how great they were after they get done, so they get credit.
Good luck to the Grandson.
Oh, so they’re dealing with the government, not an insurance company. Whole different ballgame. Not sure the insurance commissioner would have any interest.
“Seems like the insurance company would think it might be wise to invest in a safe flight home after investing thousands of dollars in a transplant procedure.”
The investment the company has is a contractual agreement. They took money for the service, they are bound to execute. But unless it is specifically written in the policy, in advance, the return trip has to be completed in a particular way within the guidelines of the policy, then they are guilty of breach. And they would most likely pay for a far greater amount of money from the court’s award than the trip home and prior refused services. And the insurance commissions, probably along with the FTC and the AMA would cut them a new back hoe. They’d be paying for that for years or until they filed for dissolution. And I don’t think they want that either. And if the judge, or jury as the amount would be well over a minor determination, take the popular idea of pain and suffering into the backs of their minds, the award will be substantial.
rwood
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