Paying the Bills: Health Insurance, Disability Pay, and Attorneys
Garry Prowe, Brain Injury Success Books
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This chapter on paying the bills is excerpted from Garry Prowe's book, Successfully Surviving a Brain Injury: A Family Guidebook.
In 1997, Garry's wife, Jessica, sustained a severe brain injury in an automobile crash. "At the time, I spent way too much time accumulating the information I needed, not only to understand the medical aspects of Jessica's brain injury, but also to handle the myriad insurance, financial, legal, personal, and family issues that accompany a serious blow to the brain. I recognized the need — that stil exists today — for a book that comprehensively addresses the wide variety of issues families face in the first few months after a brain injury.
"To research this book, I assembled a panel of more than 300 survivors, caregivers, and medical professionals who resonded to my email questions and reviewed portions of my writing.
"For us, this project is a labor of love. All profits fromt he sale of this book will be donated to brain injury organizations."
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If you haven’t already begun thinking about your household finances, now is the time. You need to minimize the amount of money going out for medical expenses and maximize the amount coming in through disability pay. To accomplish this, you may want to hire an attorney. This chapter helps you sort through these issues.
When it comes to treating survivors of a brain injury, our health care system is unkind and shortsighted. The medical costs of recovery and rehabilitation can be astronomical. A patient with a severe brain injury and her health insurer easily can spend millions for her care. Acting early to understand the costs you are facing and the insurance benefits available to your survivor may help you avoid financial distress.
Health insurance — if you have it — generally covers much, if not most, of a survivor’s medical care during the acute stage of recovery. Then, it gets tricky. To recover well, every survivor of a serious brain injury must undergo extensive rehabilitation. This includes the standard physical, speech, occupational, and neuropsychological therapy, plus the newer cognitive rehabilitation.
In Confronting Traumatic Brain Injury: Devastation, Hope, and Healing — a forceful indictment of government, insurance, and medical policy regarding brain injury — William J. Winslade writes that most survivors do not receive adequate rehabilitation. This is shortsighted, he argues, since “a relatively few dollars spent on rehabilitation could make the difference between a life of dependency and one of relatively full function.”
With their eyes on the bottom line, health insurers limit what they pay for rehabilitation, both inpatient and outpatient. They typically pay for just two to six weeks of inpatient rehabilitation. Even worse, they sometimes insist that inpatient rehab be completed within a certain period of time, within ninety days of the injury, for example. This can be a big problem if your patient is slow to emerge from her coma.
With outpatient rehabilitation, health insurers usually cap the number of reimbursable physical, speech, and occupational therapy sessions at twenty-five to fifty per year or, even worse, per injury. With cognitive rehabilitation, they are even stingier.
The impairments most disabling to most survivors of a brain injury are deficits in attention, concentration, memory, problem-solving, and decision-making. Cognitive rehabilitation is the best way to remediate these complaints. Insurance companies, however, often deny payment, claiming that there is no evidence that cognitive rehabilitation is effective. Recent research, however, has concluded otherwise and the Brain Injury Association of America is leading the fight to have cognitive rehabilitation recognized by the insurance industry as standard, reimbursable treatment for a brain injury.
Many health insurance policies also have lifetime benefit caps, such as $1,000,000, that are easily exceeded with a serious brain injury. Caregivers often find that just when their survivor is benefiting the most from rehabilitation, the insurance company says, “No more.”
Every rehab program has a case manager who negotiates with the health insurer over the amount of reimbursable services. Your survivor is best served if the case manager at the rehabilitation facility you select has many years of successful experience working with health insurers.
If you fear that your health insurance benefits may be lacking, consider these nine ways to maximize them:
If you have not already informed your survivor’s health insurer about her injury, do it now.
If you have not been assigned a case manager at the hospital or rehab facility, ask for one.
Cultivate a good working relationship with this person.
Review your policy carefully, or
Have an insurance expert, an independent case manager, or an attorney who specializes in personal injury litigation review your policy.
Ask about extra-contractual or going-out-of-contract exceptions that may be mutually beneficial to insurer and patient. For example, all parties involved may agree that it’s best to cut short inpatient rehab provided the insurer picks up the tab for seventy-five, rather than fifty, annual outpatient rehab sessions. Be sure to get any extra-contractual agreements in writing.
Be sure your doctors are documenting all progress in your family member’s condition, even the tiniest. Health insurers are quick to stop payment if the patient is not progressing.
If you feel your insurer is not treating you fairly, file an appeal with the company.
If your appeal is denied, speak to an attorney.
When your health insurer says, “No more,” check out these potential sources of financial assistance for your medical bills:
Medicaid, if your income and financial assets are small (See page 120.)
Hospital patient assistance programs for people with low incomes: Talk to the hospital billing department. They may work with you to establish a payment plan you can afford.
Medicare, if your survivor qualifies for Social Security Disability Income: Medicare benefits, however, don’t begin until two years after the injury. (See page 121.)
Auto insurance, if the injury was the result of a car accident
Workers’ Compensation, if the injury occurred at work (See page 132.)
BrainLine.org is a WETA website funded by the Defense and Veterans Brain Injury Center through a contract with the Henry M. Jackson Foundation. Government funding support is not an endorsement of WETA or any of its products, including this website.