Guardian Nurses Nurse Advocate Monica Nash, RN, BSN, has been working with a patient and his family to ensure that he continues to get the therapies he needs — despite reaching the original limit allowed by his insurance company.
After a serious bike accident, a young man was in the ICU for six weeks with a traumatic brain injury (TBI). During this time, his wife was asked if she wanted to withdraw life support. Repeatedly, she said no — explaining that her husband had so much energy and life before the accident, that she was sure he would be able to get through it.
From the ICU, he was discharged to a rehabilitation center that specialized in helping patients with TBI.
When he finally returned home to his wife and two small children, he was still weakened on one side, similar to someone who’s had a stroke. He needed help dressing, bathing, eating, toileting, and transferring himself in and out of his wheelchair.
His insurance benefits provided in-home therapy, including physical therapy, occupational therapy, and speech therapy, plus some outpatient therapy. In addition, he received covered outpatient therapy, including aqua therapy and working with an exoskeleton to help him learn how to walk again.
He was making significant progress, getting out of his wheelchair for more extended periods and improving his speech. Then, the insurance company told the family that he had used up all the therapy that had been allotted for the year. It was March.
Luckily, Guardian Nurses knows how to fight that fight. Nurse Nash connected with the social work case manager and nurse case manager on the insurance company’s catastrophic event team, and they all partnered together to present his case to the right decision-makers. They were able to explain the whole picture: the family support, the progress he was making, what he would lose if unable to continue, and his short-term goals and long-term goals.
Nurse Nash successfully secured more in-home therapy and outpatient visits. As a result, by August, the patient was able to use a walker instead of a wheelchair and is able to make his own transfers from sitting or lying down to standing safely.
Nurse Nash’s advice: Get to know your insurance plan and what’s covered under your benefits. If you are denied coverage, keep pressing. You don’t have to accept the first, second, or third no. In addition, some insurance companies have specific teams who help clients in catastrophic situations — which may not be mentioned in your explanation of benefits package.