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mamasbabygirl

A rant and I need help!

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Dealing with the damn insurance company/rehab case manager, the House Doctor!!!

Mom's neurosurgeon told us before surgery that mom's condition would worsen for at least 2-3 months after surgery and then, and only then, would she see any improvement. Our impression pre-surgery was that she would be in rehab for 2-3 months or until she got better. This is not the case...

I know some of you have had to go through something similar, so here goes:

Rehab has already determined that mom will be at wheelchair level upon leaving on 2-15. We have a case manager who works with her insurance company and a "House Dr." is what I call him that approves or does not approve her rehab stay. He would not even fill out her LTD paperwork for her job bc "he won't be her Dr. when she leaves". The oncologist did it, thankfully.

I got a call from the case manager today who said mom will be at wheelchair level and be needing 50-75% help with transfers once she does home. So, she was calling with the phone #s for a ramp service and a stairlift company. I asked about insurance and she said they consider the stairlift/ramp a convenience item!! My parents live in a tri-level. Main floor has no potty and 5 stairs outside. Full bath is up with the bedrooms and a family room and half bath downstairs.

When we push the case manager to defy the norm with the insurance company considering her Dr. told us 2-3 months before she would make improvements, she starts talking about assisted living or adult daycare. SF did not realize assisted living is a nursing home, so he was all game. He is not ready to do this again, she is far worse off, believe me. She has no movement in her leg now. God, I am so angry!!!

Help me please come up with some solutions to deal with this lady and the insurance company. The policy has no lifetime limit.

This house Dr. is the rehab's Dr., that's where he works every day. I bet he is getting fat!!

Help!

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I am so sorry you are going through all this crap. I don't have any words of wisdom or anything that can help. but I will be praying for you and your mom to get an intervening helping hand.

Does the hospital have a patient advocate or other patient consulting service that you can talk to that might know how to make things happen?

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I don't know your insurance company but most of them now will provide an advocate for you. Call the insurance company and tell them you don't "understand" all of the administrative and regulatory stuff so someone needs to work with you. I believe they are required to assist. I hope you can get the help you need.

Trish

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Oh, Lori! I feel for you, because I think I know what lies ahead of you.

Although my dad did not have brain surgery, he was hospitalized last year for over 3 months, most of that time confined to a bed. He was extremely weak and had lost a great deal of weight (and censequently muscle mass) and went to a "rehab" facility. And yes, it's a nice name for a nursing home. They got him strong enough to sit into a wheelchair, but he had to return to the hospital and lost some progress. He was discharged "wheelchair-ready" and had physical and occupational therapy at home, but only for a few weeks. It seems that once they show the patient the exercises and make sure that the exercises are understood, they discharge the patient.

Expect your mom to need a commode. Gross, I know, but for a few weeks, it is better than trying to wrangle her into the bathroom. She will also need a walker. When she is strong enough for the toilet, get support rails for the toilet. These are easily installed and are a great help.

Will she be getting a hospital bed? These really are beneficial as they usually can be lowered closer to the floor so she can get up easier than with a traditional bed, plus the head/feet can be elevated. The mattresses leave a lot to be desired, but a memory foam mattress topper can solve that problem.

Find out how much coverge they will give her for nurse aide/home health care assistance. I doubg yout SF will be good about helping her with her ersonal care needs, especially in the middle of the night!

Boy, you are in a sticky wicket. No bathing facilities on the family room floor, so a hospital bed set up there would not be optimal unless she is ok with sponge baths only. And leaving her in her bedroom all day keeps her separated from the activity of the house and makes it hard to motivate her to do her PT exercises and receive visitors, because she would be essentially confined up there. I don't have any advice, just plead your case to the insurance case manager, and if you get nowhere, move up the chain of command. Someone HAS to be able to work with you on this!

Just an afterthought: is it possible to get into a "nicer" nursing home and get the insurance co. to pay their usual reimbursement rate and your parents pay the difference? We considered this with my dad but chose the home care option.

Hugs to you, dear. Don't try to do it all yourself!

~Suz

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lori, I don't have too many answers except basically what everyone else has already said. Daddy's insurance paid for his walker, cane, commode, rails in the bathroom etc. I think Moms insurance should cover some of this stuff but I know that is not your main concern. I just don't know what I can say... I am praying. Love, Sharon

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First, the term assisted living is now applied to all types of situations from a nursing home to an adult foster care home to a group home. You could find a small family home that would be accessible that would give her the attention and not be institutional--my Godfather is in a very nice place.

Second, you don't have to build a ramp, you can purchase a portable metal ramp that will fold up for not a lot of money. We have one at our office because we're in a historical building and can't build a ramp. I am betting you could rent this item for as long as you need it.

I wish you luck with all this.

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Try the insurance girl, with renting

a furnished 5 rooms place for them for

2 or 3 months so your mother could be

taken care of and let the insurance pay

for it.

Here in Quebec we have those places near

the hospital and you can rent for as long

as the patient needs it (doctor paper),

price is usually normal for such a place

and the insurance companies pay for it.

Good luck.

Jackie

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Thanks for the suggestions. I know when MIL moved in, I had to work the system with a thousand or so phone calls to get things arranged, so I am not above doing all of the legwork.

I guess I just think that the neurosurgeon should be the Dr. ordering the rehab, not the House Dr. Am I right? Shouldn't he have some say so? I plan on calling him. today.

Also, the other dunamic of our family is that my mom was the person who nursed everyone else at home, gma, gpa, aunt and to put her somewhere is just not acceptable to me. I would quit my job in a heartbeat if we had benefits, but I provide those for our family, so I am stuck. If I could stay home, she could move here.

I am just so frustrated that the insurance seems to have given up, they don't care...

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Lori; I have no suggetions to add. You have my prayers though.

don M

Well, in the last stages of his lung cacner, my brother was basically bedridden. He was on medicaid. The insurance paid for a hospital bed, a commode and home visit by a nurse several hours a day to bathe him and change the sheets. Maybe you could get something similar going.

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Lori,

You might consider contacting your state's Board of Quality Assurance which oversees and handles complaints against both Medical Facilities, Practioners, and the Insurance Industries. And if all else fails embarrass the heck out of them by going public. Contact the press.

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Sounds like that's how it should be to me, Lori. I think sometimes we need to make noise to get things to happen. It's a shame it must be like that, isn't it? Keep asking and double checking until you feel satisfied.

Kasey

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Yes it seems logical to me that someone should have rehab until they are either rehabilitated or have gone as far as they're going to go. Did you check with the neurosurgeon's office about ordering the rehab?

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Ok, I spoke with the neurosurgeon's sidekick this morning and she said that they have nothing to do with what happens at rehab. She was very understanding, she was, but she says it is all up to the rehab Dr, the therapists there, etc. She did say that if the rehab folks will not approve a stairlift/ramp that they will write a letter of medical necessity for us, so that is good. This is IF mom gets to come home.

You guys know the situation (SF and mom are still doing the same things at rehab), so if you were me, which would you try to influence?

A) Mom comes home w/the possibility that SF argues with her constantly, but she is at least at home.

B) Mom goes to a skilled nursing facility. THis thought terrifies me!!

I feel like I need to go to SF this weekend and find out from him what he is thinking. If he still says he can't do it, then I guess we will talk to mom and start looking at places. If he wants her to come hone, I will start getting everything arranged to make things as safe and easy as possible.

I really didn't think things would turn out this way, but it is what it is. I am sad.

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(((Lori))) You all are in my prayers. I think it is a good idea to talk to SF and see how he feels about her coming home and if he can give her the kind of care she is going to need. If he doesn't feel up to it then I think you might be suprised at some to the facilities out there for rehab. Of course I don't know what your moms inusrance will cover, or where you live, but we found a nice place for my mom. Of course there are some pretty aweful places too. The first place we took mom seemed aweful and we did not leave her there. Then we found the other place. Ask the social worker at the hospital what she recommends and then go visit all of them. My husbands mom is at the one my mom was at, she just had knee replacement surgery. Wishing you the best these are such tough decions to make.

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I never ever thought we would be making arrangements to see these "skilled nursing" facilities, but we are. SF, me and my uncle are meeting Monday to stop in on the 3 places that their insurance will cover. I personally think that my uncle and SF will be surprised at what we find on Monday, but maybe I will be the one who is surprised. SF says he cannot do this alone. What if she has to go to the bathroom after the nurse leaves? True, very true...

My uncle and I agree that if the skilled nursing facility does not offer intense rehab, mom will not go. She could just veg at my house for God's sake!

We still have not run anything past mom bc we are afraid she will get upset and stop rehab. We are doing the legwork and that way we can be informed when the decisions need to be made. Is this wrong?

I plan on focusing this weekend on spending some nice QT with mom. We all deserve it after the week we've had. We have a lunch planned at rehab for Saturday and I will take the kids over on Sunday for pizza or something..this makes me happy.

I love you guys..

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Lori,

I just want to say that your mom is so blessed to have you. I think you are doing the absolute right thing to check everything out ahead of time. Enjoy your QT with mom this weekend.. Know that you have my prayers. I don't always post because you have had problems that I couldn't begin to know how to handle. God Bless.

Love and Prayers,

Sue

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Lori,

I think you are wise to obtain all the information you can before presenting the best options to your mom. In her emotional state, it is best to give her firm options so she does not attach to one option that really may not be viable.

Good luck Monday. I hope at least one of the facilities is very nice and can offer all the services she needs.

Enjoy the weekend!

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Lori,

I had almost the same situation. When I was in hospital, they assigned me a house doctor, only because I was admitted through ER. He would not call my onc. GP or Nuerosurgeon. I said ok, I'll call them and they can give you orders.

I called them and they were in to see me within a few hours.The house doctor did not know my medical background and wanted to start giving me bllod thinner shots in the stomach. Didn't need that. In middle of night, I awoke to a nurse sitting at my bedside trying to give me a shot in the IV to slow down my heart. I told to get the [email protected] away from me. I was released two days later, I had pneumonia.

I also have a casworker with my insurance and she is also an oncology nurse. She gets thing pushed through for me...

Hope this helps.

Love Ya and prayers,

Karen

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