Hello Constance,
Yes, there is something you can do. You can go through QualChoice's
appeals process and, if necessary, request an external review. Please
let me start with the disclaimer that using Google Answers is not a
substitute for legal advice. At the end of my answer I've included a
link to assist you in finding legal counsel if you so desire.
My experience with nursing home levels of care (skilled, intermediate,
and custodial) comes from working in the hospital setting. One thing
that many families do not realize is the volume of documentation that
is necessary prior to a patient's admission to a nursing facility.
I've seen cases in which omissions, errors, or hastily completed
documentation have negated a patient's eligibility for skilled
coverage. Knowledge of the types of paper work required and the types
of care ordered for your son by his physician(s) will help you
navigate the appeals process.
So let's start with the admission documents typically required for
nursing home admission. These include a current history & physical
(often abbreviated as H&P), physician's orders, and a preadmission
review/level of care evaluation (sometimes abbreviated PASSAR).
Insurance companies often place great emphasis on the primary and
secondary diagnoses on these forms in making their determination
regarding payment of benefits. Therefore, one of the first steps you
can take is to compile a complete record of your son's admission
paperwork. And you can also request a record of his doctor's orders
since admission to the nursing home.
I have seen patients who were able to qualify for coverage of skilled
care when misinformation on admitting paper work was corrected. For
example, a diagnosis which would ordinarily qualify a patient for
skilled services was recorded as a secondary diagnosis rather than the
primary diagnosis, so the initial claim for coverage was denied. One
thing to bear in mind is that sometimes the physician who writes
admission orders (or diagnoses) is not the physician who writes orders
for continuing care after the patient is admitted to the facility.
This can be problematic if the physician who completed the admission
paperwork wrote skilled orders but the attending physician at the
facility does not continue those orders.
When I refer to skilled care, I am referring to skilled nursing
intervention or services such as physical or occupational therapy that
meet the Medicare skilled care guidelines. Most insurance companies
use Medicare criteria (or a variation thereof) in formulating their
guidelines for skilled benefits. The link below outlines skilled care
in a bit more detail.
Medical Requirements: Medicare Skilled Level of Care
http://www.veritusmedicare.com/provider/manuals/snf2/skilled_level_care.html
Here is another link which gives examples of skilled vs. intermediate
levels of care. Please bear in mind that QualChoice very likely does
not adhere to these exact definitions. But I'm including the link for
instructive purposes. Half way through the article you'll find
specific examples of skilled and intermediate care in a general sense.
Understanding The Medical Level of Care Needed To Qualify For Medicaid
http://www.elderlaw-sc.com/articles/1543/
Nursing Home and Family Living Insurance
(Discusses the three most common levels of care.)
http://www.insuranceplanningguide.com/nursingfamily.html
At this point I have a word of caution for you. In my experience, the
terms “intermediate” and “custodial” are often interchanged in
conversation, but they are two different levels of care. It's
important that you get your son's level of care in writing.
You stated that your son “does not move or talk.” It's possible that
he was denied skilled coverage because of an inability to participate
in skilled therapies. Some insurance companies insist that the patient
be able to actively participate in skilled therapies, whereas others
provide coverage if the skilled service is necessary to prevent
further deterioration in medical condition. For example, some
companies require that a patient be able to ambulate a certain
distance to continue a skilled physical therapy gait training benefit.
Others might cover more passive range of motion exercises to prevent
atrophy. I was not able to find anything online in which QualChoice
specifically defined "skilled" care.
The link below provides a good overview of how to be proactive in an
appeals process and what types of documentation and records you should
request.
Your Guide to the Appeals Process
http://www.patientadvocate.org/resources.php?p=13
In reviewing QualChoice's web site, I found the following: “To obtain
an appeal, you or your representative must submit a written request
for an appeal to QualChoice, Attn. Appeal Department, 6000 Parkland
Boulevard, Cleveland, OH 44124. You must submit your written request
within 180 days of receiving this determination.” I suspect that you
will also need to file an “Appointment of Representation Form” if one
is not already on file on your son's behalf.
Source: QualChoice Appeal Process (See #11 on this page)
http://www.qualchoice.com/content/Faq.asp
In many states, you are entitled to an external review if you receive
an unsatisfactory decision from your insurance company's appeal
process. Ohio, where your insurance appears to be based, does provide
for external review.
QualChoice's web site includes online handbooks. A quick review of the
HMO and PPO handbooks finds that the appeals and external review
processes are discussed within. You can take the link below and view
the handbook which is most appropriate for your son's policy.
Member Handbook
http://www.qualchoice.com/content/handbook.asp
You may want to consider getting an attorney to assist you. For help
finding an attorney, the list of state bar associations below may be
helpful.
LawInfo.com Bar Associations
http://www.lawinfo.com/barassoc.html
I'll conclude with a few more links which I hope will be of assistance
to you.
QualChoice Web Site:
http://www.qualchoice.com/
Ohio Department of Insurance
http://www.ohioinsurance.gov/
Insurance Appeal Denial
http://www.chhelp.org/appealdenial.html
Nursing Homes Overview
(Lots of general information which may be helpful, even though your
son isn't on Medicare.)
http://www.medicare.gov/Nursing/Overview.asp
Search terms:
ecf + level of care
extended care facility + level of care
insurance + appeal + process
insurance + external + review
If any portion of my answer was unclear or not helpful, please ask for
clarification prior to rating this answer, and I will do my best to
continue working with you.
Warmest regards,
fsw |
