WHENEVER there is a catastrophic injury or illness resulting in a traumatic brain injury (TBI), the injured person, family members, court-appointed guardian, and healthcare providers face the difficult task of identifying the range and depth of benefits from entities such as private health insurance, government, special education, and disability programs.
Court-appointed guardians and families have relied on receiving long-term nursing care, home care, and therapy benefits for individuals with TBI, and frequently need these services to keep their loved ones at home. In the past, health insurers would not discontinue home care nursing for individuals with TBI until many years after injury. Today, managed care insurers, health maintenance organizations, worker's compensation carriers, and the self-insured have instituted a plan that quickly limits skilled and attendant care nursing benefits after discharge from the acute care, subacute, or rehabilitation facility.
When an insurance company or a payer notifies a family that it is no longer paying for services for an individual with TBI, the families are confronted with a custodial care emergency. It is impossible to know what nursing and other TBI benefits a patient is entitled to without obtaining the entire health insurance policy. This document is called the Master Provider Agreement or Master Contract. Each health insurance company writes its own Master Provider Agreement or Master Contract and each managed care insurer or other health insurance company sets forth its own definitions under its policy. The document identifies and describes a patient's benefits. Once this document has been obtained, it should be read carefully in its entirety. A copy of the policy should be provided to the patient's treating physician as well.
Most patients, treating physicians, and other healthcare personnel obtain health insurance information by contacting the health insurance company, reading a brochure provided by the health insurance company or the employer, or by having someone in the healthcare community-doctor, billing person, clerk, social worker, or members of the family call the insurance company. It is my opinion that coverage information obtained in this manner is often outdated, incomplete, or even misleading.
Understanding the policy's exclusions and limitations and how an insurance company defines custodial care, medical necessity, cognitive therapies, and experimental therapies are often the key to obtaining all of the available insurance benefits. Custodial care is defined differently in each policy. Usually, "custodial care" is defined as failure to make adequate rehabilitation gains, a patient's care is at "maintenance level," or a patient's rehabilitation gains have reached a "plateau." Once a payer determines that a patient's care is "custodial in nature" according to the treating doctor, the insurance company or payer will no longer pay any nursing or other benefits.
Custodial care denials/exclusions can be successfully challenged by an appeal. To be successful, the family, court-appointed guardian, their social worker, their advocate, or healthcare providers should consider doing the following:
* Communicate the patient's needs to the healthcare provider and enlist its assistance.
* Verify health insurance coverage in writing; do not rely on telephone conversations.
* Obtain the Master Provider Agreement or Master Contract and review the "custodial care" and "medical necessity" language.
* The definition of "medical necessity" and "custodial care" should be shared with all treating doctors and nursing agencies that will be writing reports and charting.
* If the requested benefit is denied, request a "letter of denial" that states the specific reasons for the denial in writing from the insurance company.
* Determine the appeals procedure and time periods to file appeals prior to precertification or payment decisions. Internal appeals usually have 1 or 2 levels and must be exhausted before an external appeal can be taken.
* Consider hiring an attorney or another advocate to investigate aggressively and pursue a patient's appellate rights.
It is important that healthcare providers advise patients and their families that an insurance company may pay nursing and home care benefits for a few months, but a "custodial care battle" is often inevitable. Retaining benefits, long-term nursing, and home care services for the traumatically brain-injured patient requires persistence, creativity, knowledge, and advocacy. Healthcare providers, patients, court-appointed guardians, and advocates, working together as a team, can defeat custodial care denials.