Civilian TBI: The Other Story

Questions & Answers – Part of an Initiative Through the American Speech-Language-Hearing Association

1. At Civilian Traumatic Brain Injury: The Other Story, the American Speech-Language-Hearing Association (ASHA) released poll results that indicate that speech-language pathologists (SLPs) are satisfied with their care delivery, yet they also cite insurance coverage as a hindrance. How can that be?

Possibly because while they provide appropriate services and do "good" for the patients they see, they can also see insurance coverage as a major hindrance to being able to always provide that good care. A significant number of insurers do not provide any coverage for cognitive rehabilitation services, or if they do, the coverage is too limited. Many SLPs note that insurance coverage for TBI-related treatment has decreased, while at the same time there is a noteworthy increase in the severity of cases.

2. The ASHA poll indicates that some patients do not comply with care. What could explain that?

The impairment suffered by individuals with TBI contributes greatly to compliance issues. People with TBI often experience problems with attention, memory, judgment/decision-making, and problem-solving. Also, they are not always aware of the deficits they have and therefore have little motivation to improve. These factors can contribute to their not wanting to go to therapy, forgetting about sessions, being unable to figure out how to get to therapy, or being on time for it. Also, a person with TBI may not have adequate family or social support to urge compliance.

3. According to the poll, referrals to SLPs are delayed. What could explain that?

Patients may not be referred to an SLP right away due to other serious medical issues that need to be addressed first. By the time the some patients are stable enough for SLP services, they may have moved on to the next level of care. Also, with mild TBI, the impairment may be "missed" until the patients experience difficulty functioning, such as losing a job or failing in school.

4. Why is referral to an SLP important?

A referral to an SLP is vital to the ongoing improvement of the person's functional communication and cognitive-communication skills (and swallowing, if needed). An SLP can assess the person and pick up subtle difficulties that may otherwise be missed and can help the patient develop ways to communicate with other professionals and family members.

5. What are the basic steps for appealing insurance company denials?

TBI patients should appeal denials of coverage by insurance companies and urge insurers to cover TBI. Each health plan has its own process for appeals. Typically, a patient goes through several levels of internal appeal, providing support for why the treatment should be covered. After exhausting the appeal process for a given plan, 42 states allow an external review process, which ASHA strongly promotes. According to the National Association of Insurance Commissioners, if a patient prevails at the external review level, health plans must pay for the treatment.

6. Has ASHA reached out to insurance companies? What has been the response?

ASHA has sent letters to the Blue Cross Blue Shield (BCBS) Association outlining the evidence that supports cognitive rehabilitation. It has also supported various patient appeals via letters or by providing efficacy documents for independent reviews. Meanwhile, the BCBS has continued to call the treatment "investigational."

7. Where can the public get more information about TBI?

The public can find more information on the following websites:

• ASHA
• Brain Injury Association of America
• Centers for Disease Control and Prevention
• Defense and Veterans Brain Injury Center
• National Institute of Neurological Disorders and Stroke