Paying the Bills: Health Insurance, Disability Pay, and Attorneys

Garry Prowe, Brain Injury Success Books

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Multimedia

• Transcript of this video. Welcome to the first in a series of webcasts on traumatic brain injury, hosted by Doris McMillon. Concussion: Understanding Mild Traumatic Brain Injury will help you understand what a concussion is and what to expect during recovery. We are pleased to feature the following distinguished guests:
  • Dr. Jim Kelly, Professor of Neurosurgery and Physical Medicine and Rehabilitation at the University of Colorado Denver School of Medicine
  • Dr. Aditya Bhagwat, Clinical Neuropsychologist from Walter Reed Army Medical Center
  • Lesley LeMasurier, a college senior at the University of Colorado who was training with the United States Ski Team until the toll of cumulative mild TBIs ended her ski career

  Panelist Bios

  James P. Kelly, MA, MD, FAAN
  Dr. Kelly is Professor of Neurosurgery and Physical Medicine and Rehabilitation at the University of Colorado Denver School of Medicine and Associate Director of the Colorado Area Health Education Center System. He graduated cum laude with a BA from Western Michigan University, with a major in Psychology and minor in Chemistry before obtaining his MA, also at WMU, in Clinical Psychology. He earned his medical degree from Northwestern University. Kelly specializes in all aspects of traumatic brain injury research and clinical care. His scientific publications and editorials have appeared in numerous medical journals, and he is invited to speak on a variety of neurological topics across the United States and abroad. Among countless other affiliations, positions, and publications, he was lead author of the Colorado and American Academy of Neurology Guidelines for the Management of Sports Concussion, and a co-author of the Standardized Assessment of Concussion (SAC), which is the most widely used sideline mental status test in sports. Dr. Kelly is a member of the Colorado State Boxing Commission and is the consulting neurologist to the National Hockey League Players Association, to the Aspen Skiing Company, and to the US Department of Defense for blast injury and concussion. He is Chairman of the Defense Health Board's Traumatic Brain Injury External Advisory Subcommittee for military clinical care, research, and education. He maintains an active outpatient and inpatient practice at the University of Colorado Hospital. Aditya A. Bhagwat, PhD, ABPP-CN
  Dr. Bhagwat is a board certified Clinical Neuropsychologist currently working in the Defense and Veterans Brain Injury Center (DVBIC) at Walter Reed Army Medical Center in Washington, DC. He completed his undergraduate studies in Psychology at McGill University, his doctoral work in Counseling Psychology at The Ohio State University, and a postdoctoral fellowship in Clinical Neuropsychology through the National Rehabilitation Hospital in Washington, DC, and Walter Reed Army Medical Center. Dr. Bhagwat served as a commissioned officer in the United States Air Force for seven years before joining the DVBIC, where he is privileged to be able to continue serving military service members who have suffered brain injuries. Lesley LeMasurier
  A senior at University of Colorado at Boulder (CU), Lesley LeMasurier grew up skiing in Virginia until age twelve, when she moved north to attend Burke Mountain Academy, a ski racing school in Vermont. In the spring of 2003, she earned a spot on the United States Alpine Development Ski Team. Over the course of the two years (2001 – 2003) prior to joining the US Team, she suffered four concussions, and began struggling with poor balance, coordination, and strength on the left side of her body. She also began suffering from migraines and insomnia. Despite these symptoms, she accepted the spot on the team. But after many crashes resulting in a fifth concussion, a broken right leg, and torn ligaments in her left knee in early 2005, she left the development team to focus on her health. An English major with a minor in Ethnic Studies, she is also a member of the CU Varsity Ski Team, but given her history of mild TBI, she is medically ineligible to compete. However, she continues her relationship with athletics by assisting with ski team training sessions, mentoring freshman student-athletes in the athletic department at CU, and serving as a board member and the athlete representative for the Shelley Glover Ski Education Foundation. She plans to pursue an MFA in writing upon completion of her undergraduate studies. About BrainLine Webcasts We've launched BrainLine's webcast series to keep you informed — on an ongoing basis — about preventing, treating, and living with traumatic brain injury. Listen, watch, and learn from top experts in the field — from neurosurgeons and speech pathologists to long-time caregivers and individuals living with TBI. Concussion: Understanding Mild Traumatic Brain Injury
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  My son’s court case related to his TBI just settled. I want to be sure these funds are available for his care. How should I best do that?
   
  Click here to go to About Ask the Expert. What to Know About Trusts and Structured Settlements After Brain Injury
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  My wife and I are planning our estate and we want to make sure that our daughter, who needs fulltime care after her brain injury, is provided for financially. What kinds of things should we be talking about with our attorney?
   
  Click here to go to About Ask the Expert. Planning Your Estate

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.

Health Insurance

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.

1. If you fear that your health insurance benefits may be lacking, consider these nine ways to maximize them:
2. If you have not already informed your survivor’s health insurer about her injury, do it now.
3. If you have not been assigned a case manager at the hospital or rehab facility, ask for one.
4. Cultivate a good working relationship with this person.
5. Review your policy carefully, or
6. Have an insurance expert, an independent case manager, or an attorney who specializes in personal injury litigation review your policy.
7. 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.
8. 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.
9. If you feel your insurer is not treating you fairly, file an appeal with the company.
10. 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.)