This blog is a chronology of our story and should not be used as the basis for medical treatment or diagnosis. From time to time, you will find links to other websites that we have found helpful, however we offer no guarantees as to the accuracy of these websites. At all times, please use your own good judgment and the advice of qualified medical physicians and specialists.

August 11, 2007

Friday, May 7, 2010

Saturday morning.

This entry will make you angry -- be prepared. Michael is caught in an insurance nightmare that we are hoping desperately will come to an end on Monday. As you know, Michael needs to be on 24 hour nursing care most days and all nights for the hospital to discharge him. The insurance company has only pre-certified 5 days. Nothing will change with Michael in 5 days, though. In the meantime, the hospital has been trying to staff the 5 days, but the preferred in-network provider will not take on "temporary" clients, as they do long-term nursing only. The other in-network provider does not have sufficient staffing available. So, we still wait.

On Friday , the hospital began prepping Megan for what they perceive to be a pending battle with the insurance company to keep Michael in good care. The real rub is that the insurance policy is written for unlimited "medically necessary" nursing care, and if it hadn't been, then Michael would have qualified for Medicaid to pick up any gap in nursing coverage.

To make the morass bigger, the insurance company next denied Michael any further hospitalization. In doctor to doctor consults, the insurance company stated that the inability to staff Michael's nursing care was "not their problem".

Late Friday evening, a glimmer of hope came. Something finally worked, with a case manager from the insurance company finally calling to discuss the specifics of the situation and to say something other than, "I'm sorry, but I can't help you." They began advising on how to approach the appeal process, but then later called back and asked that we stop all formal appeals pending a review of the situation by the Medical Director first thing Monday morning (California time). We have not agreed to stop any pending appeals, but Megan and Adam have agreed to temporarily abstain from filing any new ones by themselves. We have, however, told them that the hospital's decision to pursue any pending or new appeals was out of our control.

And there we are, waiting again. The temporary case manager let us know that something we have done has made waves and got the attention of people who can make a difference. It really stinks that valid medical claims can be given appropriate consideration only when someone is not afraid to make a real pain of themselves. I know a lot of the progress came because Megan's law firm employer made a lot of phonecalls on our behalf, but for Michael , we will take any advantage we can.

We don't know how things will turn out on Monday, but you can bet we won't be giving up. Things look hopeful now.

On a brighter note, Adam passed his certification exam on Friday. He has been in classes all week, and now he gets to add some initials after his name.


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