Alright. So things were good. All I needed to do was call up the SNF the next morning, on Feb. 22nd, and tell them what I found out from my mom's insurance company. So I woke up all excited, feeling like this great weight was going to be lifted off of my shoulders.
I called up the SNF and spoke to the same woman who I talked to the previous day. She said that even though my mom DOES have 100 days, the notes that a physical therapist put in her records indicated that she no longer needed Skilled Nursing care and that her last covered day would be the 23rd. My last choice was to appeal the decision.
Later on that day I got a certified letter from the SNF, informing me that my mom's coverage would end on the 23rd. So ONE DAY before my mom's coverage is to end, I get a letter saying it is going to end. WTF is that all about?
This is the criteria on which they based the reasons for my mom being ready to leave:
"You are able to transfer with stand by assistance and ambulate (walk) 100 feet, two times with stand by assistance. Would care may be provided at a lower level of care, i.e. Home Health Services in your home setting."
Okay, I had never seen my mom walk unassisted. At that time she could barely walk in a walker unassisted. I don't know where they got this info or what type of crack they were smoking. I wanted to SEE this. To this day I want to SEE this and see what they're talking about. But I'm such a little scaredy-cat that I won't. Plus what good would it do? I doubt it would affect the insurance company, who is TAKING THE WORD OF DOCTOR WHO NEVER SAW MY MOM, WHO IS TAKING THE WORD OF A PHYSICAL THERAPIST.
So we decided to set up an appeal. This is done through an independent company and it usually takes about 24 hours. I should have done it after the first call I got on the 21st, but ended up trying to get things sorted out with my mom's insurance company all day. Then on Wed. I thought it was resolved and found out I was wrong. So for the days that she was not covered, we had to pay out-of-pocket while the appeal was being processed. It was just so frustrating. Just when things start to seem okay, something else goes wrong. I'm just afraid we'll either have to pay a lot of money, or have to bring her home before she's ready. And either I would have to move home temporarily or we'd have to hire someone to come take are of her...my dad couldn't do it alone and we couldn't afford to hire that kind of help.
The first time I called about the appeal, we talked to someone in charge of the appeal process, and she assigned the appeal to someone who I will call Dave. Dave was very helpful. Basically he said if the appeal was approved, we'd get two more days before we'd have to file ANOTHER appeal, and so on and so on. What the hell kind of system is that? We'd just keep getting two more days for my mom to stay until they decide to deny it? What's the point of filing an appeal? And if we got denied, that was it, there was nothing else we could do. The appeal basically consisted of an independent doctor READING my mom's medical records. No one going to visit her...in fact she hasn't even SEEN a doctor since she went into the SNF.
On Friday the 24th, I got a call from Dave saying that the appeal was denied. I was, of course, devastated. He said that it could have gone either way but that the doctor said he agreed with the primary doctor (who? no doctor saw my mom!!!) that wrote the initial end of coverage notice or whatever. Dave told us we could sort of "appeal the appeal" though. This is called a reconsideration. The only problem with that is we still have to pay for my mom to stay while it was being investigated. So basically what happens in a reconsideration is that a SECOND doctor READS my mom's medical records to see if he agrees with the main doctor.
So I called Jeff at work and talked briefly about what we should do. I was just exasperated and didn't feel like making any more calls. Jeff went over to visit my mom...the SNF is so close to where he works that he can walk right over. Jeff was talking to one of the nurses and when she found out that the appeal was denied and my mom would have to leave or do private pay, she was surprised to hear this because she thought mom wasn't ready to go home yet. Many of the staff also said that to my mom as well.
Jeff talked to my mom as to how she felt about coming home. She said she wanted to come home but she didn't feel physically ready, and that she felt scared about coming home because she was afraid of falling or hurting herself in some way. But NO doctor has seen or listened to her to see how she REALLY was. I don't understand how a decision like this can be made by ONE physical therapist.
So, with all that in mind, we decided to go with the reconsideration, which we called about on Sat the 25th. We left a message with one of the on-call staff because Dave was out for the weekend. So we had the whole weekend to wait. More waiting. Since it was a three-day weekend, we'd have to wait even longer!
On Tuesday the 28th, Dave called and told us that the reconsideration had been denied and that my mom's coverage officially ended on the 24th. So shit. What do we do now? Well, she's been in there since the 24th uninsured, so we'd paid for that thus far. But now what?
I thought I'd take this to my mom's primary care physician. I called and asked him if there was anything he could do to intervene. I told him my mom hasn't seen a doctor at all since she's been at the SNF, and that the actions she was supposed to be able to do, the ones that are stated in the document we received, she is unable to do (sorry for that horrible sentence). He said he couldn't do a thing. He said he was notified of the appeals as well and there's nothing he can do about it. It's all in the hands of the insurance. Yeah. So. Don't be afraid of the damn insurance. DO SOMETHING!!! Dick.
At this point she was basically staying at the SNF just to have her dressings changed, eat, rest, be watched over, etc. We know she doesn't really need that but she does need to have things done for her that she wouldn't be able to do at home, and we were hoping that she would be learning to walk again. But since the physical therapy was cut off and we were basically paying for her to stay there with minimal rehabilitation training...well what should we do?
So I decided to DO SOMETHING!!! I called her insurance company and told them her situation, and asked if there was anything that could be done. The man I talked to said that her insurance would cover what I thought was a decent amount...we wouldn't have to pay a whole lot.
On Tuesday the 28th, my dad had an appt. with their doctor, and I asked Dr. Dick about at least getting my mom physical therapy. I told him about the info. I got from her insurance company and gave him their phone number. He said to leave it with the front desk and he would take a look at it.
On Thursday the 30th, I got a call from someone at Dr. Dick's practice. She told me that the doctor had approved physical therapy through a local physical visiting nurses association. The purpose of this facility is to do therapy and such outside the home when necessary. But here's the catch...the insurance company has to approve it. So what do you think is going to happen? Seriously, I have not heard from the insurance company yet. I have absolutely no concrete idea. I have my own ideas, but after working for two weeks with this damn insurance company, I'm not even going to bother crossing my fingers. Having said that, if everyone who is reading this would cross theirs, it would help a lot.
So here I sit, waiting again.
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