Insurance question - Update

[lovemysons]

Hi Goldie,

Just wanted you to know I did write two appeal letters for Insurance purposes when my son's went to Drug Rehab years ago.
Seems like they were 10 to 12 hand written pages long! I wrote everything down that had transpired with their behaviors (in school and at home), how drug use was destroying their lives, why it was so detrimental (to society as well as the family unit) that they continue with treatment, what we all were learning while they were in treatment etc. It was basically an "I beg of You to help my son" letter. In both cases we "won" the appeal process.
My oldest son stayed at rehab for 6 months and my younger son for 4 months.

I hope you have a good weekend at the "FEP" and enjoy your lunch visits with your son.
I too have a talented "singer" in my oldest GFG. My young GFG is more the artist type.

Glad you found us Goldie,
LMS

[Goldie]

lovemysons, thank you so much for your post! It is exactly what I was hoping to hear.

So H and I got back home on Tuesday night. The Family Education Program (FEP) at the rehab facility where gfg has been for the past three weeks ran from Saturday through Tuesday. It was intense and amazing. I was so impressed by everyone we met there, including the other parents. (There were seven families, and over the course of the four days, we got to know each other quite well.) H and I learned a lot, and had some significant "Ah hah!" moments about how to deal with our gfg.

On Monday, at the end of the day, we had a family therapy session with gfg and two counselors -- a substitute counselor (gfg's regular counselor is on vacation this week, which is okay) and a clinical supervisor. I was blown away by that session, and so happy that gfg is working with these people. The clinical supervisor met with H and me beforehand, and coached me on how to try to get gfg to disclose a significant secret that he had been keeping from us. (I had suspicions about this secret -- having to do with how he earned money to pay for drugs during his two months of couch-surfing -- but did not know anything for sure.) Gfg did open up to us, and it was a very moving moment. I felt as if I could almost see the waves of anxiety flowing off him, at not having to keep this secret any longer.

I was also impressed that it took only about a week and a half after arriving there for gfg to realize that he did need extended care. I knew that going in, and we did not hide it from gfg, but I knew he was hoping he would just do the 31 days and then be able to come back home. That would not be good; his triggers are his friends here, and there is not one of them who does not do drugs. His GF is probably the worst offender; he has seen her do heroin. (He has not tried that, but recognizes that it could be down the road if he continued to hang out with his old friends. Despite that insight, he is still focused on the GF, whom he loves and wants to rescue, so his coming back home at this point would not be good.)

The facility has just made its recommendation for extended care. I was impressed by the thought they put into that. Gfg will be going to a facility down South (we're in the NE), and from what I have read and heard about it, I think it will be a good fit for him. He is actually pleased with the choice, and is very willing (5 on a scale of 1 to 5, he says) to continue treatment.

I do realize that the future could be full of ups and downs, and am very aware of the possibility of relapse. But for now, I believe that gfg is where he needs to be, and my feeling after having attended the FEP is one of great relief.

Okay, about the insurance and finances -- H and I met with the financial person right before we headed home. I had been communicating with her by email, and already had a good impression. That impression was confirmed by the meeting. Like everyone else there, she is intelligent, compassionate, and dedicated.

For our insurance, there are two levels of appeal. The first level can be initiated either by the patient (or in our case, by me, as gfg's authorized representative) or by the treating facility. I had been thinking that I would do the Level 1 appeal, but after speaking with the financial person, I decided to let the facility go ahead and do that, and if their appeal is denied, then I will do Level 2, and write the kind of letter that lovemysons did.

I am actually somewhat optimistic about the chances of prevailing. In the Initial Adverse Determination letter, the insurance company spelled out their findings in support of their decision, including that gfg "is not reportedly at risk of harm to self" and that "[t]here is no severe impairment in the member's . . . social support system such that the member is likely to use substances if not in 24-hour care." I think that the facility, with what they know now (gfg is very forthcoming with them), should not have trouble making clear that those conclusions are flat-out wrong. The irony is that I wish that gfg could manage with IOP rather than inpatient care -- it's not fun for us having gfg be three hours away! -- but the fact is, he used drugs every single day, because all his friends did, some of them even more than gfg. As to the risk of harm, from what I know now, I believe gfg was at very real risk of physical harm, from a friend of his whom I believe is actually psychotic. (A sad case, as this friend is brilliant and very talented, but scarily and increasingly divorced from reality.) I am just 100% positive that if gfg were at home, doing IOP, that he would do drugs every single night. And because of how he was earning money for drugs and because of his friend whom I believe is psychotic, I believe his life was actually in danger.

I don't want to give the impression that I am naive about the possibility of success on the insurance appeal, but I at least feel that it is worth the time and effort, and that it is not tilting at windmills.

Thank you all for your advice! I am so glad I decided to post here.

[Nancy]

That's wonderful news and I can hear the hope in your words. Knowing that gfg is in good hands with professionals who know what they are doing and a plan in place for his extended care is truly a comforting feeling and probably is the only thing that allows you to go to sleep at night.

I agree that if he were at home going to IOP he would continue using. They need to be out of their environment. The sooner the insurance companies get this the better it will be for all our gfgs struggling with addiction. I have hope that the treatment center will be able to convince them of this.

When our gfg was in the treatment center we had parent education day every sunday. It was extrememly intense and like you we got to know the other parents very well. We left physically and emotionally drained for our long drive back. I wanted to bottle up those feelings we had with gfg and keep them safe, it was the first time ever that we saw her vulnerable and willing to look at her life in an honest way. We did a lot of crying and hugging but I wouldn't have missed it for anything.

I'm glad things went so well. Please keep us updated on his progress.

Nancy

[Goldie]

Thank you, Nancy! It helps so much knowing that other parents here know what I am talking about.

I will keep you all updated -- and if I don't, please don't hesitate to nudge me, as you did last night. I am a terrible procrastinator and struggle with time-management issues, but I know I would respond to a direct appeal for an update. Having said that, I will try to post updates without having to be reminded!

[Goldie]

Interim update: Gfg is just a week away from moving from the primary care rehab facility to an extended care facility in another state. He was all for this move earlier this week. This morning, he told his counselor he has changed his mind, and wants to come home. SIGH.

We had a conference call, with DH, myself, one of gfg's counselors, and gfg. Gfg, who is 19 years old, knows that our position is that he is on his own if he does not agree to extended care. We are going ahead with plans for the transfer, in hopes that gfg will change his mind again over the course of the next week, and agree to go. I have some hope, partly because his regular counselor is back from vacation on Monday. He likes her a lot, and she has been good at getting him grounded.

But who knows what will happen? This is so stressful and -- just so tiring!

But a bit of good news: I had thought that our insurance would not cover extended care, but it turns out it does, at least in part. We will still be faced with the medical necessity hurdle, but I am told that it should be easier. So if we can only get gfg to go there, it might not be as painful financially as I had thought it would be!

[AlabamaGirl]

That's great news Goldie!

[Nancy]

Goldie,

I editted your subject to add "update"

Nancy

[Goldie]

Thanks, Nancy. I wasn't sure if I should start a whole new thread, or what. Editing the subject seems the best compromise!