posted
he's not on a ventilator, not with a heart condition or physically disabled visibly. (except for facial twitching, insomnia, light sensitivity and abnormal gait) he does have evidence of severe aquired brain injury.
he has severe neurobehavioral symptoms that make life at home and in the community deadly. this is well-proven fact based on incidents already documented.
we've been pursuing neurobehavioral rehab, he is clinically acceptable due to the brain damage that is documented fact, reactive to infectious encephalopathy. his spect scan is horrific. the centers that control thinking, judgment, impulse control, the ability to use judgment, anxiety are clearly and totally black on the scan. there is little blood flow to his brain.
while we tried to get into a neurobehavioral program, we were delayed for reasons that seem to be purely financial. they delayed too long, and he went into crisis. we did not get a yes or a no.
in the meantime, we had to place him back into a mental health facility for acute care for symptoms dangerous to himself (suicide attempts and lots more).
the plan was to have him there until he could be placed in a brain injury rehab. today, we were informed that the behavioral health arm of insurance has denied further coverage in this hospital. this was a completley surprise and outrageous denial. we have one chance at an external appeal.
this is despite dr to dr reviews and information that clearly depicts him at great risk. in addition to that, because of his brain injury, he has had severe adverse reactions to several "mood stabilizers" tried.. and the docs at the facility could see from the spect scans the reason why. the only drug left safe to try was lithium.
we are told because lithium is a compound from nature (and 150 yr old drug) that it may not effect the neurotransmitters in the same way the newer drugs do. we agree that is the way to go, as an attempt to alleviate enough of his suffering to render him ok to do further rehab/lyme treatment.
despite the fact that he has all of this data and head of hospital advocating for the need to titrate slowly and carefully - anthem behavioral health with bc/bs denied two internal reviews advocating for these needs -- that he needs time to be titrated slowly and monitored. this is a "no-brainer" (no pun intended)
i understand this is true of lithium no matter the circumstances, it must be monitored carefully as it is titrated up to the therapeutic dose.
it was medically necessary to titrate him from a small dose slowly upward, becuase of his medical history (lyme aside).
the hospital was confident that medical necessity was clear.
despite all that, insurance has denied coverage for any further stay, stating that:
1. he is not "actively suicidal" (well, of course not, he is in a locked unit with no access to so much as a butter knife)
2. that litium titration could be continued in less intensive care situation, i guess that means at home -- this is not true. this drug needs careful initiation even without organic brain disease.
3. that his brain injury could also be dealt with at a lower level of care (based on what? what care?)
we cannot afford to pay the hospital (who does not want to discharge him because they believe it is not safe) and we do not nave confirmation of acceptance to the neurobehavioral unit as of yet. so, nowhere safe to take him.
if he has to leave hospital and not be directly admitted into sub-acute intensive care program, i believe he will die.
if not in an immediate fashion, he could well do something that will land him in jail, which is death for anyone with brain injury. because his brain injury is driven by infection, he will only get worse under stress and without treatment.
can anyone help us?
i doubt it because i have called hundreds of people in the past two weeks.
adolescents with these symptoms are thrown in the trash.. why are their lives worth so much less than young children and adults??
why? i could not be working harder, it has been 24/7 for months.
why? there is clear brain damage, forget the lyme for now.
why? it's not his fault.
why? if it were any other part of the body than the brain this injured, we'd have access to some acute care.
why?? why do we have to face losing our son. he cannot be home or in the community like this. he cannot be treated at home at this time without risk to his life (hence the admition to this hospital in the first place)
is there anyone out there who can help us?
we are willing to do anything, talk to anyone, make any effort.
he has severe brain injury, lyme or no lyme, this is fact. please help.
mo
Posts: 8337 | From the other shore | Registered: Jul 2002
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bettyg
Unregistered
posted
mo, my heart goes out to you!
so far, it's a VERBAL denial; NOT WRITTEN DENIAL?
i'm sending you a pm of someone to contact who may be able to assist you ok!! keep us informed!
prayers headed to your son/you/entire family!
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feelfit
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Member # 12770
posted
Oh Mo,
I have nothing to offer except my support, my heart goes out to you....
Praying that you find an answer soon. God bless.
Feelfit
Posts: 3975 | From usa | Registered: Aug 2007
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Tracy9
Frequent Contributor (1K+ posts)
Member # 7521
posted
Lower level of care may mean nursing home or a rehab center; even if not the one you want maybe in the interim a better option than nothing.
Contact Department of Mental Health and apply for services; if he can become a client of theirs they open doors and pay for things.
Contact your Child Protective Services and see if they can help if you apply for voluntary services.
Have doctor document that he IS actively suicidal; they cannot discharge him if that is the case. Actively suicidal means if he leaves he is going to be actively suicidal. Is he able to contract for safety? Can he clearly state he poses no risk to himself or others upon leaving, and is he mentally competent to attest to that?
Get a competency exam done. If he is incompetent they cannot discharge him home.
Contact your State Representative.
Contact the Insurance Health Commissioner.
Apply for free care at the hospital.
Apply for Medicaid, or Medicare, clearly he is disabled, have you applied for SSI?
Good luck, hope at least one of these ideas might be helpful.
13 years Lyme & Co.; Small Fiber Neuropathy; Myasthenia Gravis, Adrenal Insufficiency. On chemo for 2 1/2 years as experimental treatment for MG. Posts: 4480 | From Northeastern Connecticut | Registered: Jun 2005
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quote: the centers that control thinking, judgment, impulse control, the ability to use judgment, anxiety are clearly and totally black on the scan. there is little blood flow to his brain.
Do they try to restore brain blood flow ? Brain can regenerate, but it needs blood and oxygen it carries and other nutrients, to do it. Maybe HBOT could help.
Posts: 636 | From Wroclaw, Poland | Registered: Mar 2004
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Geneal
Frequent Contributor (5K+ posts)
Member # 10375
posted
Is there another hospital?
One with an in-patient neurological rehab?
HBOT may help.
How old is your son?
The younger you are the more "plastic" your brain is.
More likely to make new centers of control and new pathways to them.
I cannot imagine that he doesn't qualify for some type of neurological rehab.
I am so sorry. Cannot imagine what you must be going through.
Thoughts and prayers to your son, you and your family.
Hugs,
Geneal
Posts: 6250 | From Louisiana | Registered: Oct 2006
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lymemomtooo
Frequent Contributor (1K+ posts)
Member # 5396
posted
Mo, I am sick for you. I pretty much know the story and have walked in the shoes.
Call Dr. V.S. for some ideas. There may be something you have overlooked. hugs. lmt
Posts: 2360 | From SE PA | Registered: Mar 2004
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lymemomtooo
Frequent Contributor (1K+ posts)
Member # 5396
posted
What about the psych ward at Columbia and ask for Lyme Literate intervention also. Just a thought. I am brain storming the best I can. I know you are about nuts over this. Hang in there and pray...lmt
ps..for others, this is why I have always said try to get those babies well while they are young if possible. The teen complications can be terrible and even deadly..I have tried and so has MO
Posts: 2360 | From SE PA | Registered: Mar 2004
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lymie tony z
Frequent Contributor (1K+ posts)
Member # 5130
posted
Whenever the doctors were trying different brain altering drugs...
did they start with baby doses first which is recommended for persons with lyme infected
brains. Was this technique employed with EVERY drug before getting to lithium?
Whenever I was given "normal" doses for a bunch of mind altering medications before finding one
that worked for me....I would have the opposite reaction to whatever the drug was supposed to be doing.
Did I miss something earlier while I was gone for awhile....?
Is the boys neuro problems due entirely to lyme infection or did he have some other kind of trauma to his brain?
If it's the infection, I'm thinking the boy has had appropriate anti-biotic IV therapy? Followed up with orals...etc?
May I safely assume the boy has been treated against infections like, for ehrlichiosis or neuroborreliosis or babs or whatever else may have infected his brain?
zman
-------------------- I am not a doctor...opinions expressed are from personal experiences only and should never be viewed as coming from a healthcare provider. zman Posts: 2527 | From safety harbor florida(origin Cleve., Ohio | Registered: Jan 2004
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
Have you contacted patient advocacy groups and the alliances for mentally ill in your state?
Do you have access to an attorney who could help? Perhaps a letter from an atty threatening legal action should your child be further harmed might do some good?
I second Tracy's suggestion that you call every single one of your reps, local, state and federal, tell them it is a matter of life and death and politely DEMAND their assistance.
i can do online research for you if you have any need of that.
I can't imagine the hell you are in right now. Sending you and your family prayers..
Love, Dilly
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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GiGi
Frequent Contributor (5K+ posts)
Member # 259
My best to you and your Family.
Posts: 9834 | From Washington State | Registered: Oct 2000
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
general advice (CNN) on how to fight insurance company denial of coverage:
Here are some lessons from a family that's been there:
1. Get help Your doctor, hospital business office, and employee benefits office can be a lot more powerful than you are. Robinson used all of these, plus a non-profit group called the Patient Advocate Foundation, which employs 72 case managers to help people work out insurance issues.
2. Be persistent "Appeal again and again and again," says Robinson. "You may go through three or four levels of appeals before you get a favorable resolution," says Nancy Davenport-Ennis, co-founder of the Patient Advocate Foundation.
3. skipping- not relevant
4. Ask your doctor to try again Often a tweak in paperwork will change everything. For example, Bailey Robinson took one drug for two purposes:
It improved the effectiveness of his chemotherapy, and it helped his anemia. The insurance company refused to pay for it as part of his chemo. When the doctor re-filed the request mentioning anemia, it worked.
5. You may need a lawyer Steps one to four (are useful) but in the end,
it was the threat of a lawsuit (with lawyers cc'd on the letter) that clinched it.
"When they started putting 'Esquire' behind the names, that seemed to seal the deal."
.... Davenport-Ennis of the Patient Advocate Foundation says her organization, which helps patients appeal tens of thousands of denials a year, gets those denials reversed 94 percent of the time.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
gives its opinion that the 3 top bad-faith insurance companies are State Farm, Allstate and Hartford;
and that the best 3 insurance companies (the "good-faith" companies) are Chubb, Allianz and Amica. ----------------------- Remedies or Options You Might Consider
Here is a (partial) checklist I could use for someone who consults with me about an insurance company's failure to pay a legitimate claim.
Let's assume the claim is for an expensive treatment for a medical condition, and that the policy clearly indicates that there is coverage, and that the treatment is accepted by the medical profession.
1. Write a letter on my legal stationery to the C.E.O. of the insurance company demanding that he/she make appropriate payment, with reference to various issues or concerns that seem to be used improperly to reject the claim or deny coverage.
2. write a letter to the State Superintendent of Insurance describing the problem and asking for his/her help in getting the insurance company to pay the claim, or to investigate why the claim is not being paid to my client and perhaps 10,000 other insureds.
3. Write a letter to the state Attorney General saying pretty much the same thing.
4. Write a letter to the local county prosecutor requesting that he/she investigate the matter for criminal fraud and convene a grand jury, and that the client would be willing to testify;
5. start a publicity campaign by the issuance of press releases to local, national and industry media
6. Hire a public relations firm to get publicity (including show appearances) to try to generate action by government regulators against the insurance company.
7. Complaint to the Courts and get others similarly situated to complaint to the courts that the insurance company is not paying on legitimate claims;
years ago, the New York Courts dealt with this problem with one specific insurance company by having one judge set aside for the one insurance company and its hundreds or thousands of cases and then forcing the company to trial in multiple cases as the same time until it became too costly for the insurance company to try that many cases at the same time, and the company started settling a much higher percentage of the claims.
8. Use internet and other sources (perhaps advertising) to try to find other persons insured by the same insurance company who are having the same difficulty, and gather evidence which you can show to your attorney.
9. (not relevant to crisis situation but including) Find other persons similarly situated who can join with you as named plaintiffs in the lawsuit. Note: I generally do not recommend that a client commence a class action.
All too often, the client (and named plaintiff) in a class action winds up with very little, and the attorneys who bring the class action wind up with much more than the members of the class.
On the other hand, class actions are often necessary and may well represent the only way that some problems can be addressed, when the amount at stake is so small that nobody would bring suit to recover such small sum, and the wrong-doing corporation or insurance company will keep the ill-gotten gains in absence of a class action.
For your information, California has a class action law which appears to be far better for the public than the laws of any other state.
10. Commence a lawsuit against the carrier, and make allegations (if supportable) about their unlawful practices and demand punitive damages, plus the actual damages you have suffered, together with costs, interest, out-of-pocket expenses of the litigation and attorneys' fees.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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posted
Mo I am sorry you and your family are going through this.
Just to add to the other suggestions -
1) Have you asked for a nurse case mgr at bc/bs? I know some have said this is not a good idea, but I have one and she has been helpful. The ins co also had a social worker (ins co employee) call me and she was helpful too and is working on some other things for me.
2) I don't know your location but what about Dr Bransfield? He is in NJ. I have seen him speak and he is knowledgable and seems caring. He is a LL Psycbarist(?) If he can't help he may be able to recommend resources.
3) I agree with the others - call every representative, Senator, etc in your area. (You are probably doing this)
4) Send an email to LDA.
5) Accept the financial responsibility FOR NOW until you can appeal the ins and/or get a lawyer. Your son needs you and the hospital/medical bills have to accept minimal payments as long as you are paying something.
6) Call a lawyer about what I said in #5. A lawyer told me this but states may vary.
I would do what I had to do to get the proper care, fight like heck (Ins) and worry about the financial consequences later,(after consulting with a lawyer 1st).
Prayers to you and your family
Posts: 262 | From nj | Registered: Dec 2007
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posted
Wow...Im sooo sorry to read what your son and your family is going through.
How old is your son?
When was he diagnosed with encephalitis? Was it viral, bacterial, etc?
Did he receive any treatment for the inflammation of the meninges and brain?
Is he aggressive towards you or members of your family?
Does he talk openly about what he feels?
Is it possible for him to live with your family while this stuff sorts itself out, or is he too dangerous and really needs to be institutionalized for his own good and the good of others?
Is he coherent or unresponsive?
You mentioned suicide... sometimes thats a persons response because of wanting the pain and ongoing problems to end....hopelessness, dispair, and anxiety feeding on each other as the mind wants a final answer vs searching endlessly for pain relief. The longer pain and confusion continues in the brain, the harder it is to maintain control.
With encephalitis recovery, you really are into an area where the doctors simply just dont know the answers for what will work, what wont work, and how long it will take.
Perhaps its possible to schedule a sit down meeting with your pcp, insurance agent, HR person, lawyer, banker, news person, famly members, priest, rabbi ...hell..anyone and everyone who will listen, and try to calmly look at the facts, documenting everything that has occurred, and is currently happening.
Key Facts: Your son has brain damage.
Your son is in crisis.
Your son needs care.
What can they as doctors, lawyers, social workers, insurance co, media, family, friends, priest, rabbi, do to help with the situation?..now...not in months or years from now.
With encephalitis, it really is a long, long process of recovery. Sometimes there is permanent damage, but so long as the person can continue to stay positive, and see that even the littlest things are a sign of improvment, it will go a long way to restoring a person back to health, physically, and more importanly...mentally.
Our prayers are with you..!!
Posts: 514 | From . | Registered: Apr 2008
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oxygenbabe
Frequent Contributor (1K+ posts)
Member # 5831
posted
Mo, can you try hyperbaric oxygen with him? Even a mild chamber.
Posts: 2276 | From united states | Registered: Jun 2004
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JRWagner
Frequent Contributor (1K+ posts)
Member # 3229
posted
Mo, I am so sorry to hear this news. Have you contacted Sen. Hillary Clinton's office? I think you will be pleasantly surprised as to the help you can receive from them.
I wish I could help personally...
Peace, Love and Wellness, JRW
Posts: 1414 | From Ny, Ny | Registered: Oct 2002
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AZURE WISH
Frequent Contributor (1K+ posts)
Member # 804
posted
I am so sorry you and your son are going through so much Mo
I hope one of the suggestions they offered brings you some answers.
AliG
Frequent Contributor (1K+ posts)
Member # 9734
posted
Mo
I'm so sorry you're having to go through this.
All of the other suggestions I've thought of were already given.
The only other thought I have is that perhaps the Insurance Company is hoping that if they can force the dose instead of titrating they will not have to pay for any further care for your son.
That is the way that they tend to operate. It's like swimming in shark-infested water with an open wound. IT MAKES ME SICK!!!!!!
The only OTHER thing I can think of is to get Arnold Diaz ("SHAME on YOU" TV segment) or someone from a similar type TV advocacy to try to help tackle this.
Since there is a definite sense of urgency, perhaps they might be convinced that it would make for a good story.
I'm sorry I can't come up with anything else.
I'll keep you & your son in my prayers. I hope that you are able to get help.
hugs & prayers, Ali
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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I talked to hubby who has filed many many appeals with Anthem BCBS during his 7 year Lyme illness.
It sounds like you have some docs on your side who are trying to help.
We had a somewhat similar situation trying to get insurance to approve hubby's SPECT scan. Insurance said that he did not have a brain tumor or epilepsy so they denied the test. What we did was:
1) Request the reason for denial -- I think you have already done that.
2) Request the insurance company guidelines for SPECT tests -- they are required to provide this if they have denied a claim, but they won't volunteer this info or provide it unless you specifically request it -- legally they have 30 days to provide this info.
When we got the guidelines there are 7 instances in which a SPECT scan is covered -- one of the reasons was encephalopathy or brain inflammation -- By rewording the request the test was approved.
Have your doc call the corporate appeals dept. (appeal coordinator) and say it is a life or death situation or a medical emergency and ask the insurance company to fax you their guidelines for at least the following 3 items :
BCBS guidelines for admission to the brain injury rehab facility, guidelines for in-patient psych care, guidelines for lithium titration.
Once you have the guidelines then there may be something that you can base your request on. There could be something that was not discussed in the doc to doc review.
Hubby had 2 different doc to doc reviews by 2 neurologists who tried to get his SPECT scan approved, but both were initially denied because hubby did not have a brain tumor or epilepsy.
IT IS ALL IN THE WORDING. Until you have those actual guidelines you may not be wording the appeal correctly.
If there is something relevant in the guidelines then the doc should be able to ask to have another doc to doc review -- say you have new information. You should not have to go through the external review process. Or as a last resort simply submit a new request. You can also request that a different insurance company doc review the new request.
If your doc says the appeal is a medical emergency or life or death situation then the insurance company must rule on appeals very quickly. Can't remember the exact timeframe but this is probably in your insurance manual.
Hope this is helpful.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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2roads
Frequent Contributor (1K+ posts)
Member # 4409
posted
Mo,
Sending prayers your way.
Let me know how I can help.
Greta
Posts: 2214 | From West Chester, PA | Registered: Aug 2003
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Bea-
what incredibly useful (and hard won) information and advice.
your post should go into Trees' links...
d
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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lightfoot
Frequent Contributor (5K+ posts)
Member # 2536
posted
Dear Mo,
I am so very sorry to hear of this unjust predicament! My hugs and prayers for your whole family.
Seems like some good suggestions above.....hope you find a way through this dark tunnel!!
-------------------- Healing Smiles.....lightfoot Posts: 7228 | From CO | Registered: May 2002
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posted
I really have nothing to offer other than I am so sorry for you and your family. You are in my prayers
-------------------- Christina Posts: 102 | From Lacey Washington | Registered: Jul 2008
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lymemomtooo
Frequent Contributor (1K+ posts)
Member # 5396
posted
If all else fails, pray that God will intervene and help.
Please remember to keep yourself well...
If all else fails, and they force him out, put him in the car and go to another hospital..If he is as ill as you think, just sitting in the waiting room will provoke him and they will see he needs help. NOt the best answer but one out of desperation. lmt
Posts: 2360 | From SE PA | Registered: Mar 2004
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lymeladyinNY
Frequent Contributor (1K+ posts)
Member # 10235
posted
I have no suggestions but I cried when I read your post, Mo.
I feel so badly for you.
I just sent a heartfelt prayer.
- Lymelady
-------------------- I want to be free Posts: 1170 | From Endicott, NY | Registered: Sep 2006
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~ ~ Hope is a powerful medicine. ~ ~ Posts: 2775 | From MN | Registered: Apr 2001
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
possibly relevant NY laws on insurance/denial of care, etc.
if nothing else, the persons and orgs mentioned might be able to help point the way.
First:
"N.Y. Consumers to Get Better Explanations When Coverage Denied"
HMOs must provide specific medical reasons for denials of services, according to agreements negotiated by the New York state attorney general.
Last October New York State Attorney General Eliot Spitzer announced a set of agreements that will enable consumers to challenge denial of coverage by health maintenance organizations (HMOs).
The agreements with six of the state's largest health insurance plans require HMOs to spell out the specific reasons for denying a treatment deemed "not medically necessary."
Under current law, plans are required to disclose the reasons and clinical rationale they use to deny coverage, but have done so only in the most general terms, according to Spitzer.
Consumers will now be told the specific medical findings on which the plans relied to support denials of service.
Seth Stein, J.D., executive director of the New York State Psychiatric Association, said, "The settlement is certainly a welcome development. We have been meeting with the attorney general and others for at least four years about problems related to denials of service.
The kind of computer-generated responses doctors were receiving about reasons for denial made appeals very difficult."
The health plans are Aetna/U.S. HealthCare Inc./Prudential Health Plan of Hartford, Conn.; Excellus Health Plans Inc. of Rochester; Group Health Inc. of Manhattan; HIP Health Plan of Greater NY Inc.; Oxford Health Plans of Trumbull, Conn.; and Vytra Health Plans of Long Island Inc.
Staff of Spitzer's Health Care Bureau examined how HMOs authorized or denied care during the period from January 1, 1999, through June 30, 1999.
This examination, said Spitzer in a press release, "revealed that these plans were refusing to pay for extended hospital stays and recommended treatment for anxiety, depression, and substance abuse, while offering nothing more than a generic phrase to justify the denial of such claims."
Some doctors treating addicted or suicidal patients were told that plans would no longer pay for the care they recommended at psychiatric hospitals because "the proposed service or treatment was not medically necessary."
The health plans have also agreed to:
* ensure that any company hired to conduct utilization review for a health plan complies with the terms of the agreement with the attorney general's office and with state laws;
* disclose to patients and their doctors that under the state's utilization review law, a plan's failure to meet the statutory deadlines for processing an appeal will result in an automatic reversal of the denial. When a plan does not meet the deadline, it must notify the consumer that the denial was reversed;
* comply with all the provisions for monitoring by the attorney general's Health Care Bureau, including maintaining complete and accurate records related to each denial; and,
* contribute $1 million to cover the costs of the attorney general's investigation.
Spitzer said his office will monitor HMOs for at least a two-year period to ensure that the plans comply with the terms of the agreement.
According to Donald Moy, J.D., general counsel of the Medical Society of the State of New York (MSSNY), the settlement will not affect the society's lawsuits against six managed care companies that together account for almost half of the managed care contracts controlling patient care in New York.
Those suits (Psychiatric News, October 19, 2001) charge the companies with "continual arbitrary denial of medically necessary care, capricious reductions in reimbursement claims, subjective downcoding and bundling of claims, as well as utilization of computer programs that deny claims based on arbitrary guidelines."
The MSSNY suit also cites "the failure of carriers to provide adequate staffing for the volume of claims being submitted and their failure to provide information to physicians about how claims decisions are made."
Moy told Psychiatric News that four of the six insurance companies have sued to shift the cases to federal courts and that no action on the merits of the cases is expected in the near future.
He mentioned, however, a recent favorable ruling in Connecticut in which a state court had decided that medical societies have the right to sue insurance companies.
((from Psychiatric News February 1, 2002 Volume 37 Number 3)
STATE OF NEW YORK INSURANCE DEPARTMENT 25 BEAVER STREET NEW YORK, NEW YORK 10004 George E. Pataki Governor
Howard Mills Acting Superintendent
The Office of General Counsel issued the following opinion on March 16, 2005, representing the position of the New York State Insurance Department
Re: Prospective Denial of Health Insurance Coverage & Article 49 of the Public Health Law
Question Presented:
Under the facts provided below, did the HMO violate Article 49 of the Public Health Law by denying insurance coverage for the health care services provided to the patient?
Conclusion:
Yes. The HMO violated Article 49 of the Public Health Law by denying insurance coverage for the health care services provided to the patient. Please see analysis below.
Facts:
The following facts were provided:
The insured was admitted to a hospital on November 1, 2004. The hospital faxed clinical information to the insured's Health Maintenance Organization (HMO) on November 2, 2004. The HMO issued a boilerplate letter on November 3, 2004, stating the following:
Care Management has reviewed the most recent medical information received. Based on the information provided it has been determined that the continued hospitalization in the above-named facility was not medically necessary of (date).
Although HMO has requested medical information for the above referenced period, it has not received the medical information needed to make a medical necessity determination. Review of medical information is the only way to determine whether the treatment proposed or delivered, based on the patient's condition, is medically necessary.
While the patient was in the hospital, additional clinical information was faxed to the HMO every two days thereafter (the 5th, 7th, 9th, 11th, 13th, 15th, and 17th of November). The insured was discharged on November 19th.
The HMO's denial of health coverage was also communicated through fax by an "End of Day Report" (Report), which is a document that provides the name of every HMO insured patient at the hospital, the admission date of such insureds and the dates for which the HMO has approved or denied the provision of health insurance coverage for such insureds.
The Report denied insurance coverage for the period of November 3, 2004, to November 19, 2004. No letter was sent after the November 3, 2004, denial letter and the HMO did not provide any verbal communication that the case was denied.
It was alleged that the HMO relied on the November 3, 2004, denial letter and did not review the case or the clinical condition of the patient after November 3, 2004.
It was also alleged that the HMO's internal policy does not permit the review of a medical director's determination that health care services are not medically necessary.
The analysis and conclusion of this opinion assume that the HMO's health care provider contract does not conflict with the requirements of Article 49 of the Public Health Law if the health care services were provided by a participating provider of the HMO, and that the HMO also sent a copy of the same November 3, 2004, denial letter to the patient or the patient's health care provider.
Analysis:
Article 49 of the Public Health Law governs utilization reviews performed by or for managed care organizations (e.g., HMOs).
N.Y. Pub. Health Law � 4900(8) (McKinney 2002) defines a "utilization review" as "the review to determine whether health care services that have been provided, are being provided or are proposed to be provided to a patient, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary."
N.Y. Pub. Health Law � 4900(9) (McKinney 2002) defines a "utilization review agent" (UR agent), in pertinent part, as "any company, organization or other entity performing utilization review."
And N.Y. Pub. Health Law � 4900(1) (McKinney 2002) defines an "adverse determination" as "a determination by a utilization review agent that an admission, extension of stay, or other health care service, upon review based on the information provided, is not medically necessary."
Accordingly, when a UR agent is not provided with all necessary medical information to determine whether health care services are medically necessary, � 4900(1) gives the UR agent the implicit power to issue an adverse determination based on such lack of information, thereby giving rise to the right of the insured to appeal such determination.
However, the UR agent must make such adverse determination in accordance with N.Y. Pub. Health Law � 4903 (McKinney 2002), which provides the following in pertinent part:
2. A utilization review agent shall make a utilization review determination involving health care services which require pre-authorization and provide notice of a determination to the enrollee or enrollee's designee and the enrollee's health care provider by telephone and in writing within three business days of receipt of the necessary information.
3. A utilization review agent shall make a determination involving continued or extended health care services, or additional services for an enrollee undergoing a course of continued treatment prescribed by a health care provider and provide notice of such determination to the enrollee or the enrollee's designee, which may be satisfied by notice to the enrollee's health care provider, by telephone and in writing within one business day of receipt of the necessary information.
Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date.
4. A utilization review agent shall make a utilization review determination involving health care services which have been delivered within thirty days of receipt of the necessary information.
5. Notice of an adverse determination made by a utilization review agent shall be in writing and must include:
(a) the reasons for the determination including the clinical rationale, if any;
(b) instructions on how to initiate standard and expedited appeals pursuant to section forty-nine hundred four and an external appeal pursuant to section forty-nine hundred fourteen of this article; and
(c) notice of the availability, upon request of the enrollee, or the enrollee's designee, of the clinical review criteria relied upon to make such determination.
Such notice shall also specify what, if any, additional necessary information must be provided to, or obtained by, the utilization review agent in order to render a decision on the appeal.
6. In the event that a utilization review agent renders an adverse determination without attempting to discuss such matter with the enrollee's health care provider who specifically recommended the health care service, procedure or treatment under review, such health care provider shall have the opportunity to request a reconsideration of the adverse determination.
Except in cases of retrospective reviews, such reconsideration shall occur within one business day of receipt of the request and shall be conducted by the enrollee's health care provider and the clinical peer reviewer making the initial determination or a designated clinical peer reviewer if the original clinical peer reviewer cannot be available.
In the event that the adverse determination is upheld after reconsideration, the utilization review agent shall provide notice as required pursuant to subdivision five of this section. Nothing in this section shall preclude the enrollee from initiating an appeal from an adverse determination.
7. Failure by the utilization review agent to make a determination within the time periods prescribed in this section shall be deemed to be an adverse determination subject to appeal pursuant to section forty nine hundred four of this title.
By letter issued November 3rd, the UR agent delivered an adverse determination that denied insurance coverage for health care services provided to the patient from the date of admission (November 1st), but the UR agent did not specify the denial's operative end date.
Notwithstanding the implication that this open-ended denial of coverage supports the allegation that the "HMO's internal policy is that once a medical doctor denies coverage that the case is not reviewed further," the HMO did not fall short of any Article 49 requirement by omitting the denial's operative end date or by, as has been alleged, disregarding any additional medical information provided after the initial denial letter (i.e., the November 3rd letter).
However, the HMO did violate Article 49 by not providing: (1) notice of the availability of the clinical review criteria relied upon in making the adverse determination, � 4903(5)(c); (2) instructions on how to appeal the HMO's adverse determination, � 4903(5)(b); and (3) what additional information must be submitted for the UR agent to render a decision for an appeal, � 4903(5)(c).
Moreover, the "End of Day Report" fax statement that "insurance coverage for the period of November 3, 2004, to November 19, 2004, is denied" does not remedy any of the above-mentioned shortcomings of the UR agent's November 3rd letter.
And standing alone as an adverse determination, the fax does not fulfill any � 4903(5) notice requirements. Nor does it communicate whether the UR agent reviewed any of the medical information that was submitted to it by fax after November 3rd.
Accordingly, under the facts presented, neither the November 3rd letter, nor the "End of Day Report" fax has fulfilled the requirements of Article 49.
Therefore, the HMO did not comply with the requirements of Article 49 of the Public Health Law by denying insurance coverage for the health care services provided to the patient.
For further information you may contact:
Senior Attorney Kristian Earl Lynch at the New York City Office.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
is Timothy's Law in NY any help--or, may be too general.
(Mo- please freely jettison any or all of the info i'm posting- i don't know what ground you have already covered. better redundant than missed info...) ----------------------
Under Timothy's Law, serious emotional disturbances are diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders in children under 18 years of age, together with one or more of the following conditions:
* Serious suicidal symptoms or other life-threatening self-destructive behaviors; * Significant psychotic symptoms (hallucinations, delusions, bizarre behaviors); * Behavior caused by emotional disturbances that place the child at risk of causing personal injury or significant property damage; or * Behavior caused by emotional disturbances that place the child at substantial risk of removal from the household. ---------------------
can't find concrete application to mandating crisis hospital coverage.. dunno.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
DO YOU NEED INFORMATION REGARDING MENTAL HEALTH, ADVOCACY or LEGAL SERVICES?
CALL THE MHANYS' MENTAL HEALTH INFORMATION CENTER
AT 1-800-766-6177
"YOUR FIRST STEP FOR MENTAL HEALTH INFORMATION AND RESOURCES"
MISSION STATEMENT: MHANYS is a 501(c)(3) not-for-profit organization with 30 local affiliate MHAs serving 52 counties in New York State.
MHANYS and the affiliate network work to promote mental health and recovery, encourage empowerment in mental health service recipients, eliminate discrimination, raise public awareness with education, and advocate for equality and opportunity for all.
MHANYS accomplishes these tasks through the following programs: Consumer and Business Outreach Program (CBOP), Community Mental Health Promotion (CMHP), Mental Health Information Center (MHIC), Parents with Psychiatric Disabilities (PWPD) Project, and Public Policy & Advocacy.
MHANYS works to ensure available and accessible mental health services for all New Yorkers.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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posted
wow. who said lymenet is not what it used to be?
apparently, it's really that and more. this is the same outpouring of support we got when my son was 12 and near death at that time.
my heartfelt thanks for every word printed here by each and every one of you.
i was hesitant to post because i've taken my share of lashings by being too public. well screw that. the help is too valuable.
unfortunately, no matter how seasoned i've become or how hard i work, i am only one person and each lead here takes a tremendous amount of effort to pursue. i will be looking through all of these posts and try and choose the top few that i know i can accomplish in a timely fashion, hedging my bets on the ones that seem most viable.
i also appreciate the treatment alternatives, but deeply ache that i cannot jump on any out-of-the-box treatments right now, as much as i'd prefer to, because he is just too ill with brain turmoil for him to be safe anywhere other than under 24 hr supervision. believe me, we have tried as much as long as we could to keep him home, i would not be anywhere near a psych facility unless we were forced there. we are.
so for now, i have to put HBO and other treatments along those lines aside, as much as i hate to. but please put forth anything you think may help along those lines just the same, because when he is more stable, i will go for the best treatment, rather than pure survival strategies.
i hope that makes sense.
over the past two days and another 50 calls, i have managed to get to a major buyer of this insurance contract through a state wide union that has purchased their plan (a huge contract).
that board of directors guy has offered monday am help to apply serious pressure on the insurance company internally to explain or reverse this denial. money talks so we have a shot with him. that means i have to have a file for him asap to work with. we have enough, as stated above, with the facts excluding lyme, and what the docs can and will state.
we know if lyme is mentioned, we get a rubber stamp. so forget lyme for now. he is clearly and severely encephalopathic.
hey, we don't know what's causing the brain injury (wink) .. maybe it's not tbd's (another wink) we can only go by the facts. the fact is his brain has little to no blood in it. who knows why...
undeniable facts as of now:
he has documented acquired brain injury that is severe (no matter the cause)
he has a long history of severe and rare adverse reactions to meds that effect the brain.
lithium was the last to try, and that drug itself must be titrated and monitored carefully no matter what, especially with organic brain disease.
he is mid-titration, not even stabilized or checked for blood levels at therapeutic dose as of yet.
to state that he can continue titration outside of medical supervision (as i understand it) is a grossly medically negligent claim in and of itself. (not to mention the severity of the symptoms it has been prescribed for, and that we have no indication the lithium is taking care of those symptoms which are life-threatening)
that is the pure and basic argument for the need for acute care in the psych facility. luckily, the facility agrees, and will not release him as per these reasons. (but insurance cut out as of three days ago). we have been told to allow the doc to keep on this track, so we may then apply for appeal. we have no money left to our names. but, we cannot take him home. period. the hospital is not releasing him.
we have to keep him there, and must now fight for coverage.
then, we have the neurorehab facility front which we need to transfer him to. he clearly meets clinical criteria for TBI/ABI (lyme aside). we will advocate for continued abx once we are in there, i have a state ombudsman lined up to do that once he is in. that i believe i can handle. (believe it or not)
we are being held at bay by an admissions gate keeper.. a money counter, who, because she HAS NOT SAID NO, must not have a good reason to say no.
on that front, i am beginning to think it is the noisy, legislative, pr or whatever pressure that can help there.
BEFORE they come up with a reason to say no, and/or if they are already clearly untoward by making us wait too long.. (i believe they have an obligation to say yes or no by now, or refer us somewhere else.) we need to apply serious pressure on them straight away, before thay drudge up reasoning for a no answer.
so, hilary is an interesting idea...but it is exhaustive to communicate with an office like that.
does anyone know if she does move quickly? (politics aside, of course)
the facility is money conscious (but cannot deny for that reason, we have insurance, but they get extra from the state for tbi patients that they cannot get for my son because of age, this is not a legal reason for them to hold us back).
but i believe more than money, they are concerned with public image. this is a very progressive and innovative program.
i know without lyme treatment he may just churn and churn there, but it is our only hope. i'll find a way to fight for lyme treatment somehow, right now i just need him safe from imminent danger to his life.
i'm gonna read over all again here.
not sure if i have repeated myself, but any ideas that stand out to you based on what i have just shared would be appreciated. hey, they have cut our legs off to our knees as of now, but not to the hip just yet.
i'm committed to simply keep going. there has to be a way. no matter what a mess he has become, his life is just so worth it. he is so angry, translation = he is scared to death.
but, i know he's still the same wonderful person, embroiled in this disease.
mo
[ 20. September 2008, 01:10 AM: Message edited by: Mo ]
Posts: 8337 | From the other shore | Registered: Jul 2002
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
you moved mountains to get that board of directors- union- money guy in your corner- that kind of power/money guy does not come easily.
i know you are surviving and battling one minute at a time, but i hope you can see for yourself that you are being EFFECTIVE.
Thank God the hospital is not releasing your son, the very least reason being that is a meaningful piece of evidence that may help force the insurance company to do the right thing until your son can safely transfer to brain rehab.
About contacting Hillary. She has a single staff person who is responsible for overseeing everything related to health care/insurance.
I have met with and am in touch with those staff members for Maryland's senators, and can for sure on Monday tell you who that person is in Hillary's office, if you can wait til then.
i'll PM you if i can get that info sooner.
Mo, the baby you brought into the world is still there, and because of you, he still has a chance.
Please let us know if we can help in any way.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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Marnie
Frequent Contributor (5K+ posts)
Member # 773
Has anyone ever set up a donation fund for a patient like this?????? Can we get Mo to go to a local bank to start one, and then we can all come together and help as much as we can?????
THIS IS EXACTLY WHY I'M TRYING SET UP 'PRODUCT GREEN' with Apple Corp. I was planning to start a thread on this, but was waiting to make sure I had all of the correct info. on it.
Has anyone heard of 'Product Red'?? You punch that into search, and I think y'all should be able to find it.
It is where someone started this project with Apple to raise money for people in Africa with HIV for medication and proper treatment. It is very succesful. I have been e-mailing them to see if we can start something like this with anything that is green.
I should have mentioned that anything in red that is purchesed, (i-pods, nanos, computers, ect.) a certain amt. goes to this orginazation.
I will post all of the info. on another thread, but this is why I think it is SO important to start an organazation for cases like this that need money!!!!
Anyway---I'm just soooooo angry right now; it's not right!!!!!
Posts: 351 | From Georgia | Registered: Feb 2008
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lymemomtooo
Frequent Contributor (1K+ posts)
Member # 5396
posted
up for more help...
Mo --Pam Weintrab, not sure I am spelling her last name correctly...Is from the Clinton's neighborhood. Today she said many there are victims, so try Hillary...lmt
Posts: 2360 | From SE PA | Registered: Mar 2004
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
from Sen Clinton's webpage regarding constituent services:
My staff makes every effort to assist New Yorkers with a broad range of issues.
However, by law, there are some matters over which I have no jurisdiction. This section will help you determine if I can be of assistance as your US Senator.
I am able to provide assistance to you if:
1. You are a New Yorker, AND 2. Your problem is with a federal government agency.
If I am unable to help you, I will try to provide you with an alternate means of assistance. However, it is important for you to understand that:
1. While I can make inquiries on your behalf about the status of any pending cases before any Federal agency, I CANNOT force a Federal government agency to decide an issue in your favor, or to overturn a decision that is final.
2. If you are seeking assistance with a case that involves a STATE or LOCAL government agency - you should send your case to your NY State Senator or NY State Assembly person or your local representative.
Any inquiries that you send my office that involves a state or local government agency will be forwarded by my office to your state and/or local representatives.
3. If you are seeking assistance with a case that involves a LAWSUIT or LITIGATION, Senate rules prohibit me or my staff from giving legal advice or intervening in proceedings.
If you need to find a lawyer, you should contact the American Bar Association Correspondence Unit at (312) 988-5522. You may also wish to contact the New York State Bar Association at (800) 342-3661.
What my staff and I need from you:
Once you have determined that your case involves a Federal government agency - the best way for you to obtain assistance from me is to FAX all the information requested below that will enable my staff to review your case and work on your behalf with the appropriate Federal government agencies.
1. A clear and concise letter describing the situation with which you require help.
2. A Privacy Waiver Authorization Form that gives my staff the authority to handle your request.
3. Please be sure to include any identification numbers such as your social security number and case or file numbers.
4. Please be sure to include a daytime phone number and your address to enable my staff to reach you should more information be needed.
FAX the information requested to my NYC office at 212-688-7444.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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You truly are an exceptional Mother. My prayers to you and your family. It is a nightmare what you have to go through to get help, and I hope things work out so that your son gets the help he needs.
Thank heavens your son has you, but, please, take care of You, also.
lifeline
Posts: 983 | From FL | Registered: Dec 2002
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posted
You know if there's anything I can do I will.
Call me if I can help. Don't know where you guys are at today, but we're thinking of you all.
Posts: 524 | From Hudson Valley, NY | Registered: Jul 2007
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bettyg
Unregistered
posted
mo, i'm so happy the board has come together again and providing many routes for you to possibly take on your son, etc!! it's a good feeling after all the fighting going on.
prayers headed your way mo for your son/you/family!
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heiwalove
Frequent Contributor (1K+ posts)
Member # 6467
posted
i have no tangible advice, for which i apologize; i wish i could do something concrete to help. please just know that you and your son are in my thoughts & prayers. you are a truly incredible mom, mo. xo.
He is on the Dr. Phil show sometimes and I always tell the kids I wish they could go to his clinic.
Peggy
-------------------- Peggy
~ ~ Hope is a powerful medicine. ~ ~ Posts: 2775 | From MN | Registered: Apr 2001
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
(sorry if you've explained this and i'm missing it).
You said the "gate keeper" for the brain rehab center is the one responsible for holding up the decision whether or not your son is admitted there.
Is the gatekeeper problem related in any way to your insurance company, or is it a completely separate problem?
Have the insurance company thieves indicated whether or no you have preauth for the rehab?
I'm sending you a very brief PM with a question.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
from patients rights in NY webpage, with contact numbers ------------------------
Legal Assistance for You
The Mental Hygiene Legal Service (MHLS) provides legal services, advice and assistance, including representation, about all matters arising out of your hospitalization here.
MHLS is an agency of the New York State Supreme Court, and is not part of the Office of Mental Health or any psychiatric center.
MHLS staff members are lawyers or social workers who have a legal background. Their function is to help you understand and protect your rights as a patient.
If you object to being hospitalized, the MHLS can arrange for you to have a court hearing before a judge, who will decide if you need to remain. If you don't have your own lawyer, MHLS can either represent you or get a lawyer for you. It can also obtain an additional psychiatric opinion.
MHLS helps patients in other ways, including investigating complaints of patient abuse and mistreatment.
All patients, their families and others who work on behalf of patients have the right to communicate freely and privately with MHLS representatives at any time.
The names, office address and telephone numbers of MHLS representatives are posted at each psychiatric center, and staff are required to provide this information to patients upon request.
In addition, each psychiatric center's switchboard can connect a caller to MHLS or provide the telephone number. All MHLS services are free.
Telephoning for Help
The State Office of Mental Health offers a toll-free Customer Relations Line. Call: 1-800-597-8481
The number for Spanish-speaking callers (en Espanol) is: 1-800-210-6456
The TDD number for callers who are deaf or hearing impaired is: 1-800-597-9810
To contact the State Commission on Quality of Care and Advocacy for Persons with Disabilities, a statewide oversight agency, call toll free: 1-800-624-4143
To contact Protection and Advocacy for Individuals with Mental Illness (PAIMI) call:
(518) 473-7378
or call toll free 1-800-624-4143
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
If You Think You Are Being Asked to Leave the Hospital Too Soon. . .
You have the right to appeal decisions made by your doctor, hospital staff or your managed care plan:
* about when you are to leave the hospital; * if you feel you are being asked to leave the hospital too soon; * if you believe you have not been given adequate or appropriate plans for your medical care and other services you may need after you leave the hospital; or * if needed services are not in place.
The law requires that you receive advance notice in writing telling you:
* The date the physician and/or hospital plans to discharge you; * how to appeal if you wish to remain in the hospital; and * a special number to call with any problems related to leaving the hospital.
For Assistance/Help
There is an Independent Professional Review Agent (IPRA) for your area and your insurance coverage.
Should you need assistance/help from the IPRA, the hospital will provide you with a phone number/person to contact.
For Medicare Patients Only
If you feel that you are being asked to leave the hospital too soon and have not received advance notice telling you when to leave the hospital, ask for your discharge notice (also called a Hospital Issued Notice of Noncoverage or HINN).
If you are in a Healthcare Maintenance Organization (HMO), request a Notice of Discharge and Medicare Appeal Rights (NODMAR).
You must have this written discharge notice in order to appeal the physician's and hospital's decision about when you are to leave. See an "Important Message from Medicare" for a complete explanation.
For Managed Care Patients
If you are a patient enrolled in an HMO or managed care plan, first request/ submit an expedited appeal to the HMO or plan's utilization review committee if you feel your benefits are unfairly limited or denied, or you are being asked to leave the hospital too soon, or that medically necessary services are inappropriately excluded from your coverage.
If you are not satisfied with the outcome of that appeal request, you may contact the New York State Department of Health by calling: 1-800-206-8125. ----------------
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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posted
thanks you all. i don't have time to answer each post or pm tonight, but i am finding help in each one so thank you again for any and all ideas.
tomorrow we have that contact i mentioned to help with insurance and i have a project with him to deal with. i'm praying he can help with insurance coverage at the hospital, and that the hospital does not suddenly deem my son fit to leave if they become skweemish about the insurance cut-off threat. technically, we do not have coverage secured since 9/15 (going on 8 days).
meanwhile, my son had at least one code orange called on him this weekend. once incident involved him being told he could not place a call home when he wanted to, and i am told he started throwing furniture.
i am torn between worry over his condition, and the validation that he obviously should not have been released home last week. if this happened under 24 hr supervision and with five staff members there in a flash, what would he have done at home or out in the community in that state. these are the kinds of outbursts we were dealing with pre-admission. i am also very concerned that the lithium is apparently not helping.
regardless, he desperately need acceptance into the brain rehab program to be kept safe longer term and possibly helped.
on that front, dilly and others, thank you so much for all of these notes. i am confused by whether hilary can help, and whether this is "federal". i want to try her office anyway, because a referral from her staff to another could be very helpful if she can't help herself.
so, if you can find out the particular aide who handles health problems, please let me know. i do very well with articulating the need to the right people. the problem has been finding someone who can do something.
i am convinced the brain rehab program has no good reason to delay us this long. it seems clear that we have the right to a yes or no by now, because if it is no we need to use this time to find another placement.
not that i haven't been looking, and the kicker is there is not another placement that i know of after weeks of research that deals with the cognitive/behavioral manifestations of severe encephalopathy.
having the pictures of his brain that are so astoundingly graphic and showing them to md's gains shock and awe responses, but no absolute help as of yet.
mo
Posts: 8337 | From the other shore | Registered: Jul 2002
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bettyg
Unregistered
posted
mo, thanks for your update. so glad dilly and all other suggestions are helping you.
best wishes today with the person helping you! praying it all goes WELL !!
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
the info about Clinton's constituency services was FYI, so you are prepared to counter staff telling you what can't be done for you.
You're right- you should definitely call. I'll work this AM on finding the appropriate staff member.
I'll PM that to you when I get it, as well as the research I've done on the rehab facility, some of which may be very pertinent to a conversation with Clinton's office.
dill
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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treepatrol
Honored Contributor (10K+ posts)
Member # 4117
posted
Mo I am so sorry.
-------------------- Do unto others as you would have them do unto you. Remember Iam not a Doctor Just someone struggling like you with Tick Borne Diseases.
checking it out now. i'm trying to be prepared for assistance, while at the same time not wanting to intimidate or **** off the facility we need help from.
i've learned fighting doesn't win, but phrasing a true plea for help with the subtle alert to the facility that we have legislative support for our son's needs, could.
thanks for the info, i'm sure i'll be able to do something with it.
mo
Posts: 8337 | From the other shore | Registered: Jul 2002
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hospital has tackled an external appeal for us, and thank god still keeping him as per his need.
we have to keep our fingers crossed and with all the help and support received i feel hopeful despite the odds against him.
lithium was doubled today.. many tbd symptoms are present, he is on mino and rifampin and if (no, when) we get to the tbi/abi sub-acute care facility the next battle is keeping him on tbd treatment.
there was some movement in the direction toward the tbi program today, but not fully secured.
thanks for all of the help here, much of it has or will help somehow.
mo
Posts: 8337 | From the other shore | Registered: Jul 2002
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charlie
Frequent Contributor (1K+ posts)
Member # 25
posted
Aha....Irish whiskey with a beer chaser....you and dilly got my attention.
I wish I could help you with the legalese Mo but my expertise is in self treating and abx combos...though still amateur.
But If you need a shoulder I'm always here.
Charlie
Posts: 2804 | From Texas | Registered: Oct 2000
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
sorry,didn't see your PM til this am- just replied.
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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lymemomtooo
Frequent Contributor (1K+ posts)
Member # 5396
posted
Up for more ideas and prayers for Mo and family. lmt
Posts: 2360 | From SE PA | Registered: Mar 2004
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
up
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
unbelievable. i'm so sorry you're going to have to go through another round.
am PM'ing you Posts: 2507 | From lost in the maze | Registered: Aug 2006
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Mo-
unbelievable. i'm so sorry you're going to have to go through another round.
am PM'ing you Posts: 2507 | From lost in the maze | Registered: Aug 2006
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hshbmom
Frequent Contributor (1K+ posts)
Member # 9478
posted
Dear Mo,
Your family is in my prayers.
Posts: 1672 | From AL/WV/OH | Registered: Jun 2006
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hshbmom
Frequent Contributor (1K+ posts)
Member # 9478
posted
Dear Mo,
Your family is in my prayers.
Posts: 1672 | From AL/WV/OH | Registered: Jun 2006
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the external appeal was denied for insurance, so i'm sure our welcome at the hospital my son is in will be worn thin by monday.
at the same time, the brain rehab facility as issued a discriminatory, arbitrary and capricious denial of my son for admittance, after leading us around by the nose for a month.
this leaves us in the nightmarish position i was so afraid of. no more hospital stay, unless they keep him based purely on medical need and charity.. and no place lined up to go.
i have tried to fight the brain rehab denial with a letter documenting the outrageous verbal denial reasons given, and cc'd many local legislators, plus the heads of the company. that may or may not help.
meanwhile, we have to find some placement where he will be kept safe until stable.
lithium is unclear as to whether it's helping at all, it definitely has not made him stable enough to be safe at home or in the community.
i sit here wondering how this can happen. guess it's about time i rent the movie sicko, cuz we're living it.
still fighting, there must be a solution. please keep up any good thoughts you might send our way. i really appreciate them.
mo
Posts: 8337 | From the other shore | Registered: Jul 2002
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bettyg
Unregistered
posted
mo,
i can't be their physically for you, but this as close as i can get to you right now!
i'm so sorry for you!! people weretossing out ideas like crazy; it's ridiculous nothing worked.
we have many LAWYERS on this board, and i have referred some to your post hoping they could give "general" info without jeopardising their licenses. i hope they may have PMed you with any ideas they have.
god, please help mo's family with their very ill son! please provide them a miracle by showing them the way. amen.
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posted
up, even tho you can't see what i wrote!
Posts: 8337 | From the other shore | Registered: Jul 2002
| IP: Logged |
bettyg
Unregistered
posted
MO, PROBLEM IS FINALLY FIXED!!!
page 3 now shows plus ALL of our invisible replies i think!!??
i'll check mine out as i go.
your pm box should be there? is it FULL??? ******************************************* that might be one of problems w/it too!!
copying this from COMPUTER QUESTIONS HERE
posted 27-09-2008 11:20 PM -------------------------------------------------------------------------------- Fixed it--found one file that tracks active topics that had some bad data inside;
I rebuilt the file and all is well now. Sorry for the inconvenience!
-Tom
--------------------
Thomas Brown LymeNet System Administrator and Founding Member
no, my pm box is not full, so anyone with ideas, fire away.
many have offered help that i'm following up on actively, but the situation remains dire.
dilly has given me allot about admission regs, the insurance went to external appeal already so i don't think we can fight that, just need to know how to fight hospital discharge.
without sub-acute neurobehavioral rehab care in place, he cannot safely be discharged. we'll figure out the horrific money situation later.
priority is medical necessity and safety.
...and, with our situation, they can't draw blood from a stone anyway. ugh.
mo
Posts: 8337 | From the other shore | Registered: Jul 2002
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