Insurance question - Update

Discussion in 'Substance Abuse' started by Goldie, Jan 31, 2012.

  1. Goldie

    Goldie New Member

    I have been following this forum since I discovered it a month or so ago -- right about the time my 19-year-old difficult child was on the verge of agreeing to go into rehab, out of state. He is there now, and so far, so good, as far as his progress.

    But I did get word from the facility last week that our insurance has refused to certify difficult child's treatment, on the grounds of medical necessity. The insurance carrier believes our son would be better off in Intensive Outpatient Treatment.

    I will be working with the rehab facility on an appeal, but I thought I would post here and ask if anyone has done such an appeal and actually prevailed. I'm afraid this appeal will be an exercise in futility, but I'm hoping to hear that it is not impossible to reverse this kind of decision.

    TIA for any insight you can give!
    Lasted edited by : Feb 10, 2012
  2. Nancy

    Nancy Well-Known Member Staff Member

    Grrrrrrr of course they feel it is not a medical necessity and he would do just as well in outpatient because it's cheaper for them. I'm glad the facility is helping with the appeal. We have appealed insurance ruling in the past (not related to rehab though) and were successful in getting them overturned. The doctor's opinion carried a lot of weight. So don't give up.

    Our insurance only paid for five days detox and five days of inpatient out of 60. Since we had $10,000 deductible they ended up paying $3,000 out of $25,000. They paid nothign for intensive outpatient since we exhausted benefits.

    The rehab center our difficult child was in did have scholarships available for people who did not qualify for insurance. Does your son's have anything like this?

  3. Goldie

    Goldie New Member

    Thanks for the encouragement, Nancy -- we will not give up!

    As far as a scholarship goes -- the facility website does mention scholarships, but we paid up front (for a 30-day stay), so I assume that we would not qualify. I might ask them anyway, but I would think that the scholarships would be for people who could not otherwise afford treatment. For us, it is a hardship, but it is not impossible.
  4. Kathy813

    Kathy813 Well-Known Member Staff Member

    Hello and welcome!

    My difficult child is 26 and had no insurance when she went to a 30 day inpatient rehab. She went to a community health center rehab and they charged on a sliding scale based on her income (which was zero). So she was charged $700 for a normal $7000 stay.

    Of course, we had to pay the $700 since she didn't have any money. The point of this, though, is that since your difficult child is an adult, the scholarship should be based on his income . . . not yours.

    Good luck and keep posting! We are glad to have you here.

  5. DDD

    DDD Well-Known Member

    Our insurance did not give us any grief about admission (he was a minor teen) but then after five days or seven the insurance company determined he was free of substances and should be released to go to community outreach. Yikes, that blindsided me. Appealing worked for a few more weeks and then, ugh, we ended up out of pocket. The second facility (we did three) had a generous sliding scale as they had sizable endowments etc. I had not explored the 2nd one at first because it was "top drawer" and I knew we didn't have the resources to pay what very wealthy families paid. What a shock it was to find that they were less expensive for us than the first. Do check all your options. Fingers crossed that your insurance company comes through. Hugs DDD
  6. Nancy

    Nancy Well-Known Member Staff Member

    We had to pay out of pocket too Goldie. What this all forced us to do after we paid over $30,000 including aftercare, was to drop her from our insurance and then being an adult without insurance and no income she would then be eligible for sliding fee scales or scholarship opportunities. Our treatment center told us their scholarships are for those who are currently in treatment and whose insurance has run out and cannnot self pay.

    It's a shame that there is so little help out there unless you have unlimited funds. We used most of our savings over the years trying to get her help and then the treatment center exhausted all the rest. The only good thing was on last years taxes we were able to deduct over $30,000 in medical expenses. Our accountant called to verify that amount was correct and we said sadly it was. I was almost hoping we would get auditted.

    Last edited: Feb 1, 2012
  7. Goldie

    Goldie New Member

    I just checked in here for the first time since last night. Thank you so much for your responses!

    Nancy, it just occurred to me yesterday that we might have a sizable medical deduction on our taxes next year. I pointed that out to my husband, but for some reason, the thought did not excite him! But, hey, whatever helps, financially . . ..

    DDD, I am glad to hear that appealing bought you a few more weeks. It does give me some hope.

    Kathy813 (and the other posters), I appreciate the information about the advantage (scholarships, sliding scales) of not having difficult child on our insurance; that had not occurred to me. I hesitate to do that, though, for a couple reasons. For one, our mental health coverage is usually pretty good. For example, difficult child had a 10-day inpatient stay at a psychiatric hospital last summer, for a major depressive episode with suicidal ideation. The charge was over $7000, but insurance paid every penny of it. We are also reimbursed pretty well for difficult child's out-of-network psychiatrist. It is only now, in rehab, that we are running into a real challenge.

    Another reason I hesitate to drop difficult child from our insurance is the worry about unexpected medical expenses. difficult child himself is a great example of that kind of surprise, as he was born 10 weeks prematurely. (The unexpected cause: my appendix ruptured. Not fun!) He spent four weeks and a day in the NICU, and the cost of that was way, way more than the cost of his current 31-day stay in rehab. We were very relieved that insurance covered everything. (Fyi, he was a trooper, and came home a healthy and happy baby!)

    On the other hand, I can already see that this has the potential to get really, really expensive, especially if the current rehab place recommends (as I expect they will) extended residential rehab. I keep saying to my husband that this had better work, because I can't imagine affording any more rehab after this year! (We did recently receive an inheritance, which helps a lot, but it is still a limited resource.) But I know that relapse is part of recovery, so -- well, we may have to consider the option of dropping him from our insurance at some point, despite my worries about that.

    My husband and I will be going to the rehab facility for four days starting this Saturday, for a family program, and at some point we will be meeting with our financial contact person there, to discuss insurance appeal strategies. Thanks to all your suggestions, I will ask her about scholarships and sliding scale payment arrangements. It may not help us, but it sure can't hurt to ask!

    Thanks again for the feedback and suggestions. I am glad I found this forum!
    Last edited: Feb 1, 2012
  8. Ephchap

    Ephchap Active Member

    Hi Goldie.

    Our situation was a little different, as my son had just turned 17. It was one of those gray areas, where the police and court system considered him an adult, but the health insurance and hospitals and rehabs considered him an adolescent.

    He did go to an adolescent substance abuse hospital, and our insurance (which he was still covered under at the time) did cover his stay. However, even though we had agreed to 21 days with the director of the program when he was admitted (as we told her we were looking for a long-term placement), he was released on day 12, as the insurance carrier said he now had all the tools and could do outpatient. That night he went out the window of our home, was arrested and has an adult felony on his record to this day. Yeah, thanks insurance carrier. He was really ready. Ughhh.

    We did end up having him evaluated once again, and found a place after making what seemed like a hundred phonecalls. I finally got someone at one of the hospitals substance abuse floors for adults that recommended I contact a certain agency that dealt with our county's MHMR. They evaluated him and agreed he needed dual-diagnostic (both psychiatric and substance abuse) long-term residential care. Our insurance carrier would not pay for anything that was considered a residential stay. The agency had us fill out paperwork to apply for SSI for him. It was based on his income (zero). As a minor living in our house, however, they also had us fill out paperwork, and they determined what we could pay. We appealed that and had the amount lowered, as by then I was not agreeable to throwing more money out and we had two other children had home. He was placed in a great facility about 2 hours from here, and he stayed there 10 months - just up until his 18th birthday. He could have stayed longer since he was already in there before turning 18, but they (and at that point, we did too) felt he was ready to transition home.

    Again, this was all very different since he was a minor. However, there are agencies that will help and that deal directly with MHMR and other agencies. The hard part (sometimes futile) is finding someone or some agency that will help.

    It should not be this difficult when someone is finally ready to get help. Unfortunately, the sad reality is that it is. Many fall through the cracks and never get the help they need because of the way the system is set up (or, in my opinion, not set up).

    My heart goes out to you. I know what a difficult situation it is to be in.

    Hugs to you and yours,
  9. PatriotsGirl

    PatriotsGirl Guest

    Kathy - since we live so close by - can you PM which facility this was so I can have it on standby? I would SO gladly pay $700 for difficult child to get into a program!!! (Course she has to want to help first!)
  10. Goldie

    Goldie New Member

    Thank you, Deb! This is all so strange for me. A year ago, I was immersing myself in the intricacies of applying for financial aid for college. I would not have thought that a year later, I would need to learn all about affording rehab. But you do what you have to do, I guess!

    I wish there were a book or a primer about this topic, though, the way there is for paying for college. I have now googled SSI benefits, but I realize I have a ways to go before I have a real handle on how we can afford this. Our insurance does not pay for extended residential rehab, so even if we eventually get reimbursement for this 31-day primary care stay, we are on our own for any subsequent care, other than IOP. So I guess -- I'd better get focused on this now!

    Anyway, we are leaving this evening for a four-day Family Education Program (FEP) at difficult child's rehab facility, and will be meeting on Tuesday with the financial person there who is helping with our insurance appeal. I'll post again next week about that.

    I don't think we get to see difficult child too much at the FEP, but we do have lunch with him two of the days, plus he will be performing an original song at chapel on Sunday. (I wish I could link to a video of him performing this song back in September at Student Talent Night at his college, but I guess that would be a problem, privacy-wise! But I have to say, the boy can compose and sing; whenever I'm down in dumps, I watch that youtube video.)
  11. lovemysons

    lovemysons Well-Known Member

    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 difficult child. My young difficult child is more the artist type.

    Glad you found us Goldie,
  12. Goldie

    Goldie New Member

    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 difficult child 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 difficult child.

    On Monday, at the end of the day, we had a family therapy session with difficult child and two counselors -- a substitute counselor (difficult child'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 difficult child is working with these people. The clinical supervisor met with H and me beforehand, and coached me on how to try to get difficult child 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.) difficult child 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 difficult child to realize that he did need extended care. I knew that going in, and we did not hide it from difficult child, 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 girlfriend 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 girlfriend, 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. difficult child 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 difficult child 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 difficult child'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 difficult child "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 (difficult child 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 difficult child could manage with IOP rather than inpatient care -- it's not fun for us having difficult child 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 difficult child. As to the risk of harm, from what I know now, I believe difficult child 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 difficult child 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.
    Last edited: Feb 9, 2012
  13. Nancy

    Nancy Well-Known Member Staff Member

    That's wonderful news and I can hear the hope in your words. Knowing that difficult child 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 difficult children struggling with addiction. I have hope that the treatment center will be able to convince them of this.

    When our difficult child 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 difficult child 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.

  14. Goldie

    Goldie New Member

    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!
  15. Goldie

    Goldie New Member

    Interim update: difficult child 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 husband, myself, one of difficult child's counselors, and difficult child. difficult child, 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 difficult child 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 difficult child to go there, it might not be as painful financially as I had thought it would be!
  16. AmericanGirl

    AmericanGirl Guest

    That's great news Goldie!
  17. Nancy

    Nancy Well-Known Member Staff Member


    I editted your subject to add "update"

  18. Goldie

    Goldie New Member

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

    Goldie New Member

    Quick update on insurance appeal: I won!!!

    Background: difficult child spent a month in residential rehab early this year. Our insurance company denied coverage on the grounds that difficult child would have been just fine in an IOP. I did an internal appeal, and the insurance company -- not surprisingly -- affirmed the Initial Adverse Determination.

    I then did an external appeal (to the New York State Department of Financial Services), and won!

    The insurance company sent the check to the rehab place, but I have contacted them and they are going to send me a refund check.

    The amount of the check: $30,035.33.

    What a relief!!!

    Thanks to everyone for their advice on how to approach this. I was especially inspired by lovemysons' experience.
  20. Calamity Jane

    Calamity Jane Well-Known Member

    That is fantastic, Goldie - you are David vs. Goliath! by the way, how is difficult child doing?