Money ($) Equals Outcomes
Joseph L. Romano, Esq.
Fortunately, medical and rehabilitation advances can make this possible in cases that previously had little hope. Unfortunately, the cost of acute care, sub-acute care, rehabilitation care, nursing care, and long-term care for people with SCIs is astronomical.
Whenever there is a catastrophic SCI or illness, family members are faced not only with the monumental task of identifying short-term medical insurance benefits, but also with identifying long-term benefits. Insurance regulations, independent medical examinations, exclusions, definitions, limitations, experimental clauses, unrealistic treatment guidelines, a biased peer-review system, and a labyrinth leading to the appellate process—when will all end?
Procedure for obtaining coverage information. How do persons with SCIs, advocates, and health care providers obtain the information to find the health insurance benefits available to an individual with SCI and his/her family in a managed care setting? There are four main ways that individuals who have suffered SCI, and their health care providers, attempt to obtain the information to determine the benefits to which the individual is entitled: (1) Contact the health insurance company, normally a toll-free number; (2) Read a brief brochure (not the master health insurance policy) which has been prepared by the health insurer; (3) Call someone in human relations or employee benefits at the person’s employer; (4) Have a family member call a person at the hospital (billing clerk, case manager, social worker, admissions personnel, or insurance liaison).
Problems with obtaining coverage information. Several problems may occur with obtaining coverage information. First, telephone coverage information provided by a clerk for a managed care insurer may be wrong, outdated, misleading, and/or incomplete. Second, managed care health insurers may fail to computerize coverage information. Third, an individual making a second inquiry to clarify information provided during a prior call can never reach the same person during a second telephone call. Fourth, efforts to obtain the master health insurance policy are often frustrated and stonewalled by the managed care health insurer.
Medical advances for the treatment of persons with SCI require that hospitals and health care providers receive immediate coverage information so adequate treatment and discharge planning can begin. Managed care health insurers are putting the burden on health care providers to treat first and worry about payment later.
Practical recommendations to obtain coverage information. Individuals with SCI and their health care providers must have the complete health insurance policy (master provider agreement), including all regulations, treatment guidelines, definitions, exclusions, limitations, and experimental clauses. To obtain the master health insurance policy from the managed care insurer, ask the health insurer to provide the document. If unsuccessful, have the doctor or the hospital request the document arguing that the health care provider cannot treat if there is no coverage. If still unsuccessful, contact the patient’s state representative or senator, or United States senator or congressperson. Finally, seek advocacy from the patient’s employer or employer’s human relations department.
The master health insurance policy should be reviewed by the patient, the patient’s family, the person identified as the health insurer who has the responsibility of identifying health insurance coverage, and the patient’s advocate or attorney. Obtaining correct health insurance coverage information for the catastrophically ill and injured is not for the meek and mild. Coverage information is the ammunition necessary to win the health care battle for dollars to treat people with SCIs. Families and health care professionals should remember that when a managed care health insurer delays providing coverage information, provides outdated coverage information, or provides misleading or incomplete health coverage, information, patients lose the benefits for which they and their employers have already paid.
Exclusions. An exclusion is a clause inserted in the insurance policy that specifically denies payment for certain enumerated services. The following are examples of exclusions that health insurers often include in their policies:
- “We will not pay for spinal cord illnesses if the condition is congenital.”
- “We will not pay if the injury happened outside the territorial limits of the United States.”
- “We will not pay if the injury occurred in a recreational activity.”
- “We will not pay if the injury occurred during medical treatment that was not pre-approved.”
- “We will not pay if the care is not medically necessary.”
- “We will not pay if the care requested is custodial in nature.”
- “We will not pay if the injury occurred as an unintended consequence of approved medical treatment.”
Health insurers place exclusions in the policy because it is good business, even though they know they will lose if they are challenged. Just because the exclusion is in the policy does not mean it is the law. Health insurers are aware that very few families challenge exclusions, and that is why they put them in the insurance policy.