Part 5: Highmark Blue Shield, 55 Minutes (Mike’s Story)

April 17, 2011

Family, Health, Mike

On Monday April 11, 2011 I was in the most elated state I had been in for a while.   Mike had been approved for Good Shepherd’s brain injury/neuro rehab program by the Physiatrist, his entire cadre of Pulmonology/Critical Care docs, Therapy and ME!  Beyond that, he was deemed medically stable enough to move by the Critical Care docs providing care for him.  The facility was willing to accept him and had a bed for late afternoon or Tuesday.  Good Shepherd Allentown has an amazing reputation with brain injury patients.  If you google them and look them up you will see they are a PICK for a major publication, rated 5 stars by the Department of Health and Human Services and can document excellent outcomes.  I was THRILLED that the stars had all lined up finally.  We were moving forward.  All systems were go.  Or so I thought.

The case manager put through a standard pre-authorization with Highmark PPO Blue our insurance company.  She came in to tell me the case manager at Highmark (HMS their approving subsidiary) wouldn’t approve it…and that she had given it to their Medical Director to approve explaining he had 24 hours. 

Late in the day Tuesday it came back denied.  They gave us some cryptic reason for it…not that it meant a thing, and we were told there could be a doctor to doctor appeal.  The Medical Director for Good Shepherd, a physiatrist, could meet with their doc to review the denial and appeal.  It would happen sometime on a subsequent day. 

I began to investigate and research Highmark’s track record with brain injury.  I discovered a precedent they set, in August of 2010 when a woman traveling to her daughter’s wedding rehearsal dinner was injured in a traffic accident.  She lost the right side of her skull and suffered a serious traumatic brain injury.  Though it does not seem she suffered the setbacks Mike did, her prognosis was similar.  About 4 weeks later she was beating the odds and they looked forward to her going to Mercy Hospital’s Brain Injury Program.  Highmark turned them down on two appeals.  They then appealed to Channel 4 news in Pittsburgh who called the office of the CEO.  Within an hour they received a phone call.  Their wish had been granted.  On third and final appeal their mom had been approved.  You can read their story here:   You can watch the video story as well by clicking on this link: 

Meanwhile, I sought out the office of the CEO of Highmark out in an attempt to reason with the giant company.  I sent an impassioned and emotional plea via email through his secretary.  She promised me somebody would look into it…and she was wonderfully compassionate.  Unfortunately, it doesn’t seem to have been enough.   The Doc to Doc appeal was denied about 5 pm on Thursday. 

We were told that we had to request an expedited appeal..and that both the facility could appeal and I could send a member grievance/appeal on Mike’s behalf.  I was told I had to request the form for expediting and have it signed by the doc.  I had 30 days to appeal.  I waited for the denials so I would know what the heck it was I was appealing.

Friday afternoon I called Highmark Blue Shield member services to ask if they could fax me the letters of denial stating the reasons.  I wanted to begin to prepare my appeal.  the (wonderful) member services rep assured me she would find out where they were and fax me copies…but wondered if I knew I had only 24 hours from denial to get the packet to them or face the standard 30 day appeal…NOT the expedited?  This had not been explained…I had no clue.  I now had a vastly reduced amount of time to get the denials, prepare and appeal and get it out to them. 

Frantically I perused the faxes.  At the hospital visiting Mike, I borrowed an office to type and launch our appeal.  I did get it in by the end of the day.  This is no guarantee they will grant the expedite OR the appeal.  They don’t make this easy. 

Basically, the initial appeal is denied because it doesn’t “satisfy the criteria for establishing medical necessity and appropriateness”.  Now I ask you.  Who needs a neuro rehab program more than somebody who has had neurological insults?  Am I missing something?  My simple country girl mind tells me that brain injury rehab is the MOST appropriate treatment for a brain injured person.  And, in order to make progress and return to any semblance of normal functioning, aggressive and early intervention is needed…and the MOST appropriate and necessary treatment!  Somebody please explain it to me like I’m six (and where the heck IS Denzel Washington when you need him????)  

The first denial goes on to say he does not meet Inter-Qual criteria (this is a standard the health care insurance industry uses for various conditions to meet qualifications).  The physiatrists evaluated Mike using the InterQual criteria.  he meets them.  The insurance company fails to say WHICH criteria he does NOT meet. 

They go on to say ” the patient has not demonstrated the ability to tolerate the required intensity of acute rehab level of care”.  TO WHOM?  He has to his entire cadre of doctors (and believe me there are many!) as well as the Medical Director and Director of the Neuro Rehab program at Good Shepherd as well as the Therapists he currently works with.  (His critical care docs have told me Highmark is the coverage for their practice.  They are so angry about Highmark’s decision and so aware that Highmark…in the acid test like this…fails to meet the needs of their subscribers…that I suspect they are reconsidering Highmark as the “Employee Choice” to borrow Highmark’s marketing slogan!) In the three days from this evaluation Mike has indeed progressed and/or exceeded most of these shortcomings.  As I said before, therapy/rehab is NOT the primary goal of the facility Mike is at.  It is their ancillary function.  That he is not worked with aggressively is not a function of his ability or lack of ability.  Yet that is the judgement rendered.  And they would move him to a nursing home where he would get less…and sit like a turnip in the field. 

The second appeal/denial was worse.  Several of the pertinent medical facts were overlooked.  At one point they say the patient is restless and distractible, requires constant cues for redirection, and is able to follow one step instructions.  Wrong.  He follows three step. One step was old news. He is progressing very quickly.  As to redirection and cues….isn’t that the hallmark of  a brain injury?  Isn’t that why neuro rehab is appropriate, necessary…CRITICAL????

This guy goes on to say “The submitted documentation is consistent with a limited potential functional prognosis and demonstrates an inability to participate and benefit from the required intensity of acute level rehabilitation therapies.  Significant progress in a reasonable and predictable time is not expected.” Thus, it is denied  though he says as progress is made submit him for reassessment. 

NEWS FLASH HIGHMARK!  Progress will NOT be made in a nursing home.  Nursing home medical treatment is NOT required.  I could provide his nursing care at home if he can stand and swallow! his medical needs do NOT require registered nurses.  His BRAIN and his physical conditioning require AGGRESSIVE rehab and every single doc involved in his care agrees.  If I take him home he won’t be ELIGIBLE for admission to acute rehab.  If I send him to a nursing home/warehouse AND he survives, so much time/ground will have been lost he may never qualify. 

Attention Highmark…the reality is that in this area there are few nursing homes that take your insurance and also take patients with a trach.  Mike may have a trach for a while…he has sleep apnea and due to the brain injury pulls off the mask and is no longer compliant with it.  Without the CPAP mask he risks his cardiac condition.  And his brain.  The trach may be there for a little while till his brain is rehabbed!!   

Of the couple nursing homes here that TAKE trach patients, they are rated one and two stars respectively on a scale of 1-5 by Department of Health and Human Services.  I want to know if Highmark’s medical director, appeal doc, or CEO would put THEIR loved one in such a place?  More to the point, I would like to know why Highmark permits their members to use such substandard and draconian faqcilities???!!!!  Are there no standards they set or benchmarks for care??? Do they REALLY just want to get it done as cheaply as possible and forget about patient safety, care, results? 

Further newsflash Highmark~!  Did you know?  I’m told that by licensure of the government, Nursing Homes may NOT accept patients who have any kind of restraints.  Mike, as a result of his brain injury is alert enough to know there are things in and on his body that don’t belong.  He wants them gone and forgets he can’t pull them out.  Thus, his PEG (feeding) tube has been a casualty already.  The trach has come perilously close…and the pulse ox sensors are changed with frightening frequency.  As a result, Mike has to wear mittens on his hands if I am not in the room.  These are considered soft restraints I am told. 

Because he is so anxious to get out of bed and walk he is perpetually putting his very long legs (He’s almost 6’5″ tall!) over the bedrails and trying to vault out of bed saying go home…walk…rehab etc.  As a result, the 4 bedrails must be up.  Again, considered a restraint. 

HELLO HIGHMARK???  WHAT IF THE SKILLED NURSING FACILITIES (euphemism for nursing home which is a euphemism for human warehouse in most cases) WON’T BE ABLE TO TAKE HIM????  How much time will you waste in his recovery? 

It seems to me, in the final analysis, that Highmark is basing their decision primarily on statistical norms for Mike’s type of illness and seeing what they want to see in what we’ve submitted.  Facts…nursing home care is covered at up to 240 days at about $800 a day for participating facilities.  Good Shepherd rehab is about $2600 day for 28-42 days.  All are agreed it is likely he can come home in 4-6 weeks given the progress he is making.  All are agreed he is the picture of what kind of patient is the penultimate brain injury program patient.  All except Highmark.  You’ve gotta ask what the heck their agenda is!!???

I will say…to Dr Marsh’s point…for simple illnesses, for the not so simple hospital care Mike has received, Highmark has been remarkable.  However, those fit very tightly into the definition of medically necessary.  there is no possible wiggle room for them not to pay.  The problem comes at this juncture…the acid test.  Can they wiggle out of paying for the more expensive treatment per day…with better results…or do they want to try to get away with the cheapest possible for the longer period…knowing that in the end it will undoubtedly be more expensive. 

My advice to you.  Highmark looks good on paper.  We certainly thought so.  They market themselves as the EMPLOYEE CHOICE.  I thought they were too.  Now, not so much.  As you are making your benefit decisions I suggest you do some research.  Ask them what would happen in a situation such as this…traumatic brain injury…chemotherapies…organ transplants…cardiac arrests that result in brain injury or stroke (all very common!).  Ask them what their record is on approving such treatments.  Ask them what kind of criteria they use.  Ask them is age a factor?  (I’ve seen 70 and 80 year old patients approved for brain injury rehab by THEIR insurance companies yet my 60 year old husband cannot get approved by Highmark…WHY???)  Ask them hard questions before you make the decision.  Ask their competitors before you choose.   Hold your legislators accountable to make health care reform MEAN something…soemthing tangible…something that will protect your family and yourself if the unthinkable happens to you. 

Meanwhile…my appeals are not exhausted.  I await their response to the current.  Mike has till the 26th where he is at now.  I can still appeal to the Commonwealth (his former employer).  Monday I visit with my State Representative.  I’m also exploring the Insurance Commission.  If only I could get Channel 6 news interested!  Anybody have ideas there?  I’ve been forced to stop working in order to deal with this.

I ask that you repost, inform, seek support for our plight.  Write to Highmark on Mike’s behalf if you feel moved?  Anything you can do is gratefully appreciated.  Meanwhile…be sure to protect yourself and your family from devastation such as this.  If you think stroke or heart attack isn’t in your future…think again…we didn’t either.  This came out of the blue and has stopped our lives temporarily.  Please don’t let it happen to you…and if you are a Commonwealth of PA employee…make sure your unions know that Highmark (and potentially its subsidiary Keystone) is not holding up in the acid test!

Thanks.  I’ll keep posting as progress is made and decisions in the appeals are made.

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6 Comments on “Part 5: Highmark Blue Shield, 55 Minutes (Mike’s Story)”

  1. Susan Santee Says:

    Robin: I can’t help but wonder who wrote the medical records that Highmark is receiving? Could the woman you “fired” still be on the case?


    • rsmallen Says:

      Susan well no, she’s not and the local facility is submitting and sending nothing of the sort. However, since the first bill was $442k exclusive of physicians, I suspect they did a chart review and it’s in the chart.


  2. aubrey Says:

    I hope you don’t mind, but I contacted 6 ABC and placed this website in the story box, and put a little explanation behind it… have you tried contacting them? We’ll see what happens, but it doesn’t hurt to try!


  3. Jess Mitchell Says:

    I just sent this out to WFMZ as well. I am hoping some light can be shed on their ridiculous policies. Keep your head up, Robin. I will pray for you.


  4. rsmallen Says:

    Thanks jess! I am grateful for any and all exposure to this situation. This impacts every single person…highmark is reputed to be one of the best insurers. If this is the best the best can do can you imagine what happens to the rest?


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