Announcement

Collapse
No announcement yet.

Recent Accident to My Son

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

  • #46
    Originally posted by Roger
    Cheesecake

    Brian's employer wants him back. Blue Shield is not steering Brian toward Shepherd. We want to go to Shepherd but Blue Shield has denied authorization. The Blue Shield doctor on the review board wants Brian to go to Santa Clara or UCLA. We want him to go to Shepherd. Brian's Blue Shield insurance is a PPO plan. The first Blue Sheild case worker told us we could go to whatever rehab facility that we wanted. Now the second Blue Sheild case worker is saying that Blue Sheild has to give us authorization.

    Roger
    Push back. The doctor wrote a strong letter, ask him to tighten it a bit if necesary. Again, UCLA does not have CARF accredidation for SCI and Santa Clara lost their Model SCI center standing. If necessary, take it to the CA Insurance Commission. Refuse transfer to CA if necessary. Shepherd is an excellent Center, the insurance company can pay now or pay later, the reality is good rehab will benefit him now and in the long run. The folks at Shepehd are also good at helping get the certification.
    Good luck and email me if you need help.

    Hopsitilization may need to be aproved, even with a PPO as this will fall into major medical.
    Every day I wake up is a good one

    Comment


    • #47
      UCLA has no CARF accredited rehab programs at all....not even general rehab. Santa Clara Valley is no longer a Model SCI System Center, and is a county hospital...and not what it used to be either, but certainly better than UCLA.

      If you must stick to CA, then either Rancho Los Amigos National Rehab Hospital in Downey or Casa Colina in Pomona would be my choices.

      Craig (Denver) is fine too, and probably equal to Shepherd. Would they let you go there?

      Is this BC/BS doctor a physiatrist? If not, ask that the authorization be reviewed by a physiatrist (a specialist in physical medicine and rehab) not just an orthopedist or neurosurgeon who is NOT a rehab specialist. it doesn't sound like this doctor knows anything about rehab centers except the ones they want to pay for.

      I would second talking to the people at Shepherd (or Craig) as they are experienced in helping convince insurances to use their programs.

      It may be too late to get a copy of this free book, but you could call the author's law office and they will help as well:

      http://www.josephromanolaw.com/

      Keep pushing. Don't give up!

      (KLD)
      The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

      Comment


      • #48
        Cheesecake

        I wrote the letter and then sent it to some people at Shepherd for their comments. Monday morning I'm going to try and catch Dr Theodore and ask him if he'll present my letter or an edited version of it to Blue Shield.

        Roger

        Comment


        • #49
          Telephoen appeal

          Roger~
          KLD gave excellent advice about being sure the BC/BS doctor is a physiatrist. Also, ask to take part in any telephone appeal that might occur.
          Rancho lost its Model facility designation and is also a county hospital like Santa Clara. Keep your focus on Shepherd and don't back down. Ask where in the policy it states they can select the facility. Generally Shepherd and Craig are centers of excellence for mos policies. Push for the access to care, it will help Brian in the long run.

          This is a difficult phase, you will get through it and Brian will see the benefits. Don't discourage and be persistant. Remember that the insurance policy is a contract and the contract is binding.

          If his employeers HR folks chime in with BC/BS, it will have an impact. They bought a product and want the best for their employees, use that avenue as well.

          Good luck and keep us posted.
          Every day I wake up is a good one

          Comment


          • #50
            Any good news Roger? Been thinking of you and Brian today.
            Every day I wake up is a good one

            Comment


            • #51
              Cheesecake

              We received authoization to go to Shepherd Tues about 11:00 am. I think Blue Shield gave authorization for Shepherd but refused to pay any transportation expense. My wife and daughter and going with Brian Wed at 8:00 am. Blue Shield sent me a letter on why they refused the transportation expense. It wasn't much of an explanation.

              1. The principle reason for the denial is that you do not meet the Blue
              Shield criteria for approval
              2. The clinical rationale for the denial is that specifically: (1) there is no
              documentation leading to the conclusion that appropriate spinal rehab
              services cannot be provided by one of Blue Shield's affiliated in state
              network providers, and (2) once an approved CA facility is selected, a
              clinical assessment will be made by both the current hospital facility
              and the receiving facility to assist in Blue Shield's determination in the
              most appropriate mode of transportation.
              3. Because the information provided shows that you do not meet the
              necessary criteria for approval, we are unable to comply with this
              request.

              Like I said this explanation didn't really satisfy me. Brian's insurance is a PPO plan so I don't understand the requirement to go to an " in state network provider ". Shepherd is a Blue Shield network hospital and the Blue Shield Evidence of Coverage says:
              "Benefits are provided for (1) Medically Necessary ambulance services (surface or air) when used to transport a Person from place of illness or injury to the closest medical facility where appropriate treatment can be received, or (2) Medically Necessary ambulance transportation from one medical facility to another."

              We doing #2 transport from one medical facility to another. I appealed the Blue Shield decision and they rejected the appeal. I'll pursue this after we get Brian into rehab at the Shepherd Center.

              Roger

              Comment


              • #52
                Great news on Shepherd. Brian needed to be transported one way or another. They should at a minimum pay what it would have cost to transport him to CA.

                Get his employeer to help contest this, you most likely will win. BC/BS has a ranking for their facilities. If you can get the score for Shepherd vs CA, maybe you can make a case.

                For now, concentrate onyour trip south. Bring lots of comfy pull up pants for Brian. Hooded sweatshirts help as well, Zippered are easy on and off. Try to bring what you think he will need, save dollars where you can.

                You might want to create a CarePage to keep Brian, and friends connected. You can get a free site at http://www.paralysis.org. The link in on the lowe left hand column.

                I wish you and your family the best on your new journey. Keep us posted.

                Yeah, Atlanta.
                Every day I wake up is a good one

                Comment


                • #53
                  I am so impressed with this site-- Care Cure-- The info and empathay is invaluable. We buy the insurance and expect it to work for us and then find we still have to fight tooth and nail for what we deserve. Thanks Cheesecake for your input in this case.

                  Comment


                  • #54
                    Roger, Let us know when you arrive in the south. Rebajane, always happy to help. We can each learn from one another.
                    Every day I wake up is a good one

                    Comment


                    • #55
                      Cheesecake

                      I'm at the Shepherd Center with Brian, my wife and daughter. Brian starts therapy on Monday. I'm very hapy with our decision to bring Brian to the Shepherd Center. The people are wonderful and the facilities look very good, better than what I saw in Phoenix at St Joesph's. I go back to Phoenix Monday morning early.

                      Roger

                      Comment


                      • #56
                        Roger~
                        Glad you made it there safely. Safe journey home to Phoenix. Shoot me a PM, there is a patient there that I know. The two guys would probably get along great.
                        Every day I wake up is a good one

                        Comment


                        • #57
                          Brian asked me a question tonight, I'm at the Shepherd Center with him. He has not regained feeling in his fingers althought he had hoped that feeling in his fingers would return. Brian sustained a C6-C7 injury 4 weeks ago, can feeling in his fingers still return? Given more time.

                          Thanks

                          Roger

                          Comment


                          • #58
                            Yes, it is possible. It is always hard to predict what will return.
                            Sometimes there is post injury swelling that occurs and it takes a while for the nerves to the injured area and areas above it to calm down and repair themselves.
                            Even though 6 months is quoted in most of the literature, changes might occur up to 2 years later, and sometimes longer.

                            CWO
                            The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                            Comment


                            • #59
                              Roger,
                              Any particular reason you chose to go to Shepherd rather than Craig?

                              Hope you are doing well.

                              Comment


                              • #60
                                Originally posted by wisci
                                Roger,
                                Any particular reason you chose to go to Shepherd rather than Craig?

                                Hope you are doing well.
                                Wisi

                                A few things influences me. We were all set to go to Craig. I had a telephone call from a man who works at Johns Hopkins, Pat Rummerfield. Pat interviews spinal cord injuried patients. He said that he has talked to almost 400 patients and he has concluded that Shepherd is the best.

                                The other thing that influence me was when I called the people at Shepherd if they were leaving work to go home they gave me their home telephone number and told me to call them at home. The people at Craig were not as generous with their time they told me call back the next day. This is a small thing but it was significant at the time.

                                I was at the Shepherd Center with my son yesterday when he was doing rehab. Mr Shepherd was there and I talked to him for almost 20 minutes. He is one of the kindest men you will ever meet. I told him that our experiece at the Shepherd Center was that all of the staff was extemely caring and kind. I believe that Mr Shepherd sets the example for the entire staff.

                                Roger

                                Comment

                                Working...
                                X