Mike Day 64: A Jubilant Day 63 Report

April 23, 2011

Family, Health, Mike

First things first.  Mom…I visited the doc for my 30,000 mile checkup (though it feels more like 200,000 miles) and all seems well.  Ticker sounds good, BP not bad all things considered, EKG looks swell…waiting for results of blood work but don’t expect anything untoward to show up.  I’ll live to see another day I reckon.  (I am also trying not to be neurotic and remind myself Mike’s picture was even better on his checkups…SIGH…instead I am convincing myself I have your constitution.)

Now, since it’s likely that if you’re reading this, you are really interested in Mike’s story, so enough of my note to my mom!

I woke up feeling really strained.  Remember I mentioned my strategy the other day?  Well, I had decided that there was no point whatsoever in the hospital sending in their appeal.  It was new information.  The insurance company seemed to have made it clear they wouldn’t evaluate new information on the old information in the context of appeal.  The appeal would tie us up for 30 days from receipt…and Mike had to be out of the hospital by Wednesday.  Still thinking like a corporate employee…and one who had made a pretty nice career starting out as a Business Systems Analyst re-engineering business processes successfully, I knew a broken process when I saw one and I thought I knew just how to handle it.  I explained to the Care Manager…take all that beautiful re-evaluation data and progress and simply use it for justification for a NEW pre-authorization.  Forget the appeal.  Asking for a new pre-auth not only will get us either approved or denied…and fast…but if denied, open up a whole new round of appeals since the old round is about exhausted.  When she looked skeptical I pointed out that in the second denial letter the Highmark Doc told us to re-assess and reapply as progress was made.  We were only following their instructions and whatever we could fathom of their unpublished process.  She, of course, needed permission from the administrator and consultation with their Director of Admissions who used to work for an insurance company doing the insurance approve/deny job.  They must have thought it was a good idea.  On Thursday our Care Manager called the insurance company to file. 

The Highmark case manager didn’t quite seem to know what to do or how to handle this request.  She said she couldn’t take a new request while an appeal was out there.  The care manager pointed out that we didn’t HAVE  an appeal out there.  Nothing had been submitted.  We didn’t WANT to do an appeal.  We wanted them to do a new case request.  The Highmark case manager said the software (I guess…she called it  an it) wouldn’t permit her to open a new case with an appeal outstanding.  Our care manager sweetly but persistently forged ahead asking her how they had handled this in the past…couldn’t she do the same or something to that effect.  The Highmark case manager allowed as how she had never had a situation like this before.  Again our care manager pointed out that the denying Highmark doc had told us to do this in his last denial letter so there must be a way.  Highmark’s case manager decided to consult a team lead and supervisory support for a method/decision.  The decision?  They would take the information as new/updated info on the original authorization and instead of the standard 30 day appeal time they would respond in 24 hours as if it were a new request.  And so now we would wait…till the close of business on Friday.  I knew my only saving grace from waiting till 5 pm for a response was that it was Good Friday…and corporations like to leave early on Holiday weekends.  I figured sometime shortly after 2 we hear. 

After the doc’s visit Friday morning, I got to the hospital and found they had taken Mike to the gym.  They worked him pretty hard…including some significant strength training.  No, that would not mean pumping iron as I had envisioned.  It meant getting him to roll over like he was rolling onto his stomach and get up on all fours.  Now I know this is something I took for granted…who can’t get on all fours?  Well, babies…not at first.  And definitely people who have been laying in bed sick for 8 weeks are challenged by this!  Yes, he got up on all fours (and those fours had to support about 255 lbs!).  After about 15 seconds there he started to try to move forward…or crawl.  The attempt was the undoing of the all fours.  His arms were wobbly…wobblier than his legs…and when he began to move one at a time forward, he went down on his face on the mat.  He wasn’t hurt…but I was surprised at how brief a period he was able to support himself and move.  I guess I had seriously underestimated the debilitation involved in being bedfast for so long.  This is a guy…who when younger and I was much thinner…was able to pick me up over his head like a feather…and who lifted some ridiculous 500 lbs or something.  Even older and out of shape, he was still very, very strong when he had his heart attack.  By the time Speech Therapy rolled around he was not interested in swallowing exercises in the slightest.  We plunked him back in bed.

As soon as he was in bed I headed out to visit the Nursing Home/Rehab that was my plan B if Highmark persisted.  The nursing home was very nice.  Still a nursing home…and though they have a great rehab department, no direct neuro experience.  Still, it would have been a great plan B.  What I liked most was that the staff and the residents/patients were all like family.  And the residents and patients I spoke with were glowing about how wonderful the care and the staff was.  I felt better about Mike going there if Highmark continued to deny. 

Dogs needed to get out and my gas tank was reminding me it was thirsty.  Mike used to pump my gas…I refuse to learn how.  Well, I know…I refuse to do it.  So I had to head for the only full service station I know of…in our little town.  I headed for gas and to let dogs out….then back to the hospital. 

Our care manager at the hospital had promised to call my cell the second she knew the lay of the land.  It was 3:00 and I had not heard anything and had pretty much decided they denied again and she didn’t want to break that to me while driving.  Though prepared for it, I remained hopeful for approval and I know she was being sensitive to the fact I would have been devastated once again. 

As I entered the hospital about 3:20 I swung by her office.  She was not there.  The Nurse Practitioner from the Brain Injury program was in there…and another care manager.  I asked if we had bad news or no news or any news and the care manager said she thought she had heard approval news but only temporarily or wasn’t sure what.  My eyes opened wide and filled with tears and I started to sway.  I could hardly believe my ears.  The nurse practitioner grabbed ahold of me and hugged me…she was scared I think that I was going down for the count.  I felt like I might…the relief was overwhelming.   We found our care manager…on the phone with the rehab hospital checking for a bed…and got the good word.  There was a bed available for that day and he was approved for a week.  The Nurse Practitioner  said with all private insurance pay patients they get, a weekly recertification must be done…no surprises there.  Our care manager got an ambulance arranged…and at 4:00 we left for the rehab with Mike grinning from ear to ear as he was wheeled out on the stretcher. 

I dedicate this post, with my undying gratitude, to Charlene, our case manager and to all the nurses, therapists and docs who took care of Mike and made this happen.  To the administration too…who was personally involved in making this happen.  You were all wonderful… and I thank you from the bottom of my heart for making sure Mike got this opportunity to regain as much of his life as possible.

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2 Comments on “Mike Day 64: A Jubilant Day 63 Report”

  1. Chris Collinge Says:

    Robin, Mike, I knew you could do it!! I’ll keep reading so Woody and I know what is going on.

    I hope, even with all that is going on, that you all have a Happy Easter!!

    Love,

    Woody and Chris

    Reply

  2. rsmallen Says:

    Thanks Chris! Love to you both and Happy Easter!

    Reply

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