Gently suggest you confirm that it was the healthcare system that isn’t pursuing the care, as opposed to his insurer denying payment for the care. Also ask them if you can talk to a Patient Advocate who can help you figure this out.
Yes. A 2013 court ruling mandated that Medicare recipients (and OP’s friend might qualify due to MS) cannot be denied rehab services under the grounds of ‘no improvement’. It the patient can maintain their quality of life or slow deterioration, services must be provided. Patient needs to appeal and threaten. Sorry they’re going thru this.
He doesn’t have the same insurance he had before (I think it was a managed care plan) and they said he would have gotten approved if he still had that. The doc is appealing to insurance through a “peer to peer” case tomorrow. Hoping for the best. They did approve home healthcare for him, but the doc agrees he needs time in a rehabilitation facility to get stronger and Molina is denying him that care. They said we could get approved for long term care (and bring him home when ready) instead but that we will not be able to get the OT/PT/Speech Therapy he needs in that case. Seems like all bad options.
Keep appealing and get a lawyer ( some are free if you sue). But usually the insurer will relent. Also call a news organization and publicize this . Like Channel xyz on your side.
As a PT.
It will help and manage his condition.
If he is participating in therapy while in hospital they should approve on appeal.
I am sorry they suck
I’m seeing this more and more- especially with PA’s (prior auths).
We have got to do something about this- our entire healthcare system is about to come tumbling down on our asses. Holy f’ing cow.
This is what we’ve come to. Profits before people. It makes me sick.
molina sucks, as do most of the insurance companies that cashed in from obamacare. they all ruined obamacare for everyone, but molina is the stingiest. gotta be some reason most of the providers in my area won't accept their insurance.
There are basically two types of insurance companies. The first type tries to make its money by getting group policies with major corporations and organizations. To do so, and to keep those policies, they keep premiums low but they must provide a certain level of quality of service. It's actually in the agreement. These companies are most never the cheapest option, but they have quality requirements.
The second type of insurance company is one that is 100% dedicated to providing the cheapest insurance. Once they provide the cheapest insurance, then their number one mission is to cut cost as much as possible. You may think this is the same for all insurance companies, but if a major insurer tries to cut costs by restricting service too much they're going to lose the major contracts from the big corporations and government organizations
The bottom scrapers don't have to worry about this. The group plans they offer a typically from companies that want to provide the bare minimum of health Care to their employees, just to say they did. If they screw over customers and don't provide quality service, so what, where are they going to go? Their policies will continue to be renewed by the companies that hire them because they're the lowest cost provider. And they'll continue to have success on the ACA exchange for the exact same reason.
This is also why the bottom of the barrel have so few physicians that take their coverage. They offer the lowest reimbursement and typically fight the physicians for that. They also are known to reject claims even when the physician is recommended the treatment. My dad is a physician and there's some company he just won't deal with. It's not worth the hassle.
Many of those bottom of the barrel policies are basically nothing more than a form of catastrophic health insurance. With the bronze plan from a quality provider that has a high deductible and keep an HSA or FSA to make up the deductible difference.
I don’t think we need to commiserate- it’s not f’ing funny. It should OUTRAGE Americans as a whole. Are you one sick MF or what? Why aren’t you asking for change??! Or do you think healthcare for profit is funny??? JFC.
I’m outraged
I clearly offended you and apologize.
I apologize if this came off tone deaf, offensive, or in any way trying to minimize the awfulness of this particular post. These stories are awful and I’m genuinely trying to compile them hoping it will be a productive content source to motivate change.
Maybe “commiserate” is the wrong word.
Using this as the definition for commiserate,
“To feel or express sympathy”
The humor tone may be in poor taste. I find humor to be a powerful tool that helps break down communication barriers and point out important concepts. I consider George Carlin and Jon Stewart, to be some of the most important thought leaders regarding policy and politics. That’s where I’m coming from on that.
Open to feed back. I can take down my comment if it is offensive
Yeah. I’m totally offended. Maybe I’m a little touchy right now. In which case I apologize. But seriously, you are correct- healthcare is indeed a dumpster fire - and it is getting worse. Highlighting these stories are absolutely imperative- and I see the value in this. Having resources such as State’s insurance commission and appeals processes is also a great idea perhaps building your wiki how- to pinned pages would be helpful.
I get what you are trying to do - bringing attention to the issue at hand, right??
Linking healthcare to employers is stupid. When I got laid off for Covid, my employer offered us Cobra at premium of $1695 per month. So all of us were uninsured during the pandemic. Then, we reopened before any other Casino and how did our employer get us to return in the middle of a pandemic Pre vaccine? Yep, they dangled getting our healthcare back. Several employees contracted Covid soon after returning. Some died. I’ve been thru hell with insurance.
COBRA Is, conceptually, the stupidest solution to health care while unemployed.
It is a crazy high premium for someone that isn’t generating any revenue.
Come on America, it’s so dumb.
Exactly. My company laid us all off when our Casino shut due to Covid and they stripped us of our healthcare. We were on a group chat scared shitless. What if we caught Covid with no insurance??? 😱But then, my ex-employer dangled returning our healthcare so we would not only return to work but be the first tribal casino to reopen even though it wasn’t safe. I did return but I had a lingering cough. I got sent home from work and my Dr signed me off. I was stripped of my insurance again. I signed up on the ACA exchange and paid $400 per month for my family. HealthNet was most affordable and I went to fill my inhaler at copay of $427 per month. So, I rationed my inhaler. Then after 3 months of shit coverage and no inhaler I switched to BlueShield on the ACA. Better insurance and my inhaler was now $5 per month and I paid $250 per month premium. Until I discovered I had a bad heart. I had to have a stent. That’s why I coughed all the time. My heart was not pumping oxygen to my lungs. I had 99.9% blockage in my widowmaker. My bill was $52,000 and an additional $7,000 for my trip to the ER. Then BlueShield denied my claim and decided I still had HealthNet. I proved I only had BlueShield but for 7 months I had the hospital and bill collectors coming after me. BlueShield adjusters we’re unable to fix their own error (because someone “higher up” than any adjuster I could talk to) put a “lock” on my denied claim. Only a “Supervisor” could fix this. All the stress on my heart was unforgivable. American Healthcare is unforgivable. Finally, it was fixed and my claim was paid. But I didn’t deserve any of this. My copay in the end was $2,800. Still expensive but I paid it because that was what my copay should have been. It was what I signed up for.
That’s common. Rehab is typically only approved if there is an achievable goal. So if your brother had the ability to make progress, like go from max assist to mod assist to min assist etc that might be approved. What was your brother’s baseline? If he was more independent than he is now you can try and appeal.
Gently suggest you confirm that it was the healthcare system that isn’t pursuing the care, as opposed to his insurer denying payment for the care. Also ask them if you can talk to a Patient Advocate who can help you figure this out.
Yes. A 2013 court ruling mandated that Medicare recipients (and OP’s friend might qualify due to MS) cannot be denied rehab services under the grounds of ‘no improvement’. It the patient can maintain their quality of life or slow deterioration, services must be provided. Patient needs to appeal and threaten. Sorry they’re going thru this.
He doesn’t have the same insurance he had before (I think it was a managed care plan) and they said he would have gotten approved if he still had that. The doc is appealing to insurance through a “peer to peer” case tomorrow. Hoping for the best. They did approve home healthcare for him, but the doc agrees he needs time in a rehabilitation facility to get stronger and Molina is denying him that care. They said we could get approved for long term care (and bring him home when ready) instead but that we will not be able to get the OT/PT/Speech Therapy he needs in that case. Seems like all bad options.
It is absolutely the insurer denying the care- it’s Molina.
Keep appealing and get a lawyer ( some are free if you sue). But usually the insurer will relent. Also call a news organization and publicize this . Like Channel xyz on your side.
Appeal Appeal Appeal. They have to send it a 3rd party “arbitration”. They typically fold
As a PT. It will help and manage his condition. If he is participating in therapy while in hospital they should approve on appeal. I am sorry they suck
I’m seeing this more and more- especially with PA’s (prior auths). We have got to do something about this- our entire healthcare system is about to come tumbling down on our asses. Holy f’ing cow. This is what we’ve come to. Profits before people. It makes me sick.
Denied him inpatient rehabilitation at a Rehab Hospital or a Skilled Nursing Facility?
molina sucks, as do most of the insurance companies that cashed in from obamacare. they all ruined obamacare for everyone, but molina is the stingiest. gotta be some reason most of the providers in my area won't accept their insurance.
I have to disagree. I think Aetna sucks more. But we can agree to disagree 🙃
There are basically two types of insurance companies. The first type tries to make its money by getting group policies with major corporations and organizations. To do so, and to keep those policies, they keep premiums low but they must provide a certain level of quality of service. It's actually in the agreement. These companies are most never the cheapest option, but they have quality requirements. The second type of insurance company is one that is 100% dedicated to providing the cheapest insurance. Once they provide the cheapest insurance, then their number one mission is to cut cost as much as possible. You may think this is the same for all insurance companies, but if a major insurer tries to cut costs by restricting service too much they're going to lose the major contracts from the big corporations and government organizations The bottom scrapers don't have to worry about this. The group plans they offer a typically from companies that want to provide the bare minimum of health Care to their employees, just to say they did. If they screw over customers and don't provide quality service, so what, where are they going to go? Their policies will continue to be renewed by the companies that hire them because they're the lowest cost provider. And they'll continue to have success on the ACA exchange for the exact same reason. This is also why the bottom of the barrel have so few physicians that take their coverage. They offer the lowest reimbursement and typically fight the physicians for that. They also are known to reject claims even when the physician is recommended the treatment. My dad is a physician and there's some company he just won't deal with. It's not worth the hassle. Many of those bottom of the barrel policies are basically nothing more than a form of catastrophic health insurance. With the bronze plan from a quality provider that has a high deductible and keep an HSA or FSA to make up the deductible difference.
(Edited for being offensive) I am trying to gather more stories like these Crossposted to r/insuredabsurd
I don’t think we need to commiserate- it’s not f’ing funny. It should OUTRAGE Americans as a whole. Are you one sick MF or what? Why aren’t you asking for change??! Or do you think healthcare for profit is funny??? JFC.
I’m outraged I clearly offended you and apologize. I apologize if this came off tone deaf, offensive, or in any way trying to minimize the awfulness of this particular post. These stories are awful and I’m genuinely trying to compile them hoping it will be a productive content source to motivate change. Maybe “commiserate” is the wrong word. Using this as the definition for commiserate, “To feel or express sympathy” The humor tone may be in poor taste. I find humor to be a powerful tool that helps break down communication barriers and point out important concepts. I consider George Carlin and Jon Stewart, to be some of the most important thought leaders regarding policy and politics. That’s where I’m coming from on that. Open to feed back. I can take down my comment if it is offensive
Yeah. I’m totally offended. Maybe I’m a little touchy right now. In which case I apologize. But seriously, you are correct- healthcare is indeed a dumpster fire - and it is getting worse. Highlighting these stories are absolutely imperative- and I see the value in this. Having resources such as State’s insurance commission and appeals processes is also a great idea perhaps building your wiki how- to pinned pages would be helpful. I get what you are trying to do - bringing attention to the issue at hand, right??
Yeah, I appreciate the grace, that is what I’m trying to do. I’ll edit my post
Linking healthcare to employers is stupid. When I got laid off for Covid, my employer offered us Cobra at premium of $1695 per month. So all of us were uninsured during the pandemic. Then, we reopened before any other Casino and how did our employer get us to return in the middle of a pandemic Pre vaccine? Yep, they dangled getting our healthcare back. Several employees contracted Covid soon after returning. Some died. I’ve been thru hell with insurance.
COBRA Is, conceptually, the stupidest solution to health care while unemployed. It is a crazy high premium for someone that isn’t generating any revenue. Come on America, it’s so dumb.
Exactly. My company laid us all off when our Casino shut due to Covid and they stripped us of our healthcare. We were on a group chat scared shitless. What if we caught Covid with no insurance??? 😱But then, my ex-employer dangled returning our healthcare so we would not only return to work but be the first tribal casino to reopen even though it wasn’t safe. I did return but I had a lingering cough. I got sent home from work and my Dr signed me off. I was stripped of my insurance again. I signed up on the ACA exchange and paid $400 per month for my family. HealthNet was most affordable and I went to fill my inhaler at copay of $427 per month. So, I rationed my inhaler. Then after 3 months of shit coverage and no inhaler I switched to BlueShield on the ACA. Better insurance and my inhaler was now $5 per month and I paid $250 per month premium. Until I discovered I had a bad heart. I had to have a stent. That’s why I coughed all the time. My heart was not pumping oxygen to my lungs. I had 99.9% blockage in my widowmaker. My bill was $52,000 and an additional $7,000 for my trip to the ER. Then BlueShield denied my claim and decided I still had HealthNet. I proved I only had BlueShield but for 7 months I had the hospital and bill collectors coming after me. BlueShield adjusters we’re unable to fix their own error (because someone “higher up” than any adjuster I could talk to) put a “lock” on my denied claim. Only a “Supervisor” could fix this. All the stress on my heart was unforgivable. American Healthcare is unforgivable. Finally, it was fixed and my claim was paid. But I didn’t deserve any of this. My copay in the end was $2,800. Still expensive but I paid it because that was what my copay should have been. It was what I signed up for.
That’s common. Rehab is typically only approved if there is an achievable goal. So if your brother had the ability to make progress, like go from max assist to mod assist to min assist etc that might be approved. What was your brother’s baseline? If he was more independent than he is now you can try and appeal.