Five ways to get payers to cover pediatric rehab
Five ways to get payers to cover pediatric rehab
You can successfully appeal an insurer’s denial of coverage for pediatric patients if you stick with it, experts say. Here are some strategies that have worked for pediatric rehabilitation providers:
• Point out the financial benefits of specialized pediatric care. One of the biggest headaches Roslyn M. Gleeson, MSN, RN, CS, faces as spinal dysfunction program coordinator at duPont Hospital for Children in Wilmington, DE, is managed care companies that want X-rays and diagnostics performed at a capitated site away from her hospital.
Since many of the contract sites are hospitals without specialized knowledge and equipment for children, the studies don’t always give the detail the physicians at DuPont want, she says. When this happens, Gleeson works with the managed care companies one-on-one to explain the problem and show why it costs more to have the studies repeated at the contract site. "They are listening because it is costing them more money," she explains.
• Educate case managers. Some managed care companies deny treatment or medical equipment simply because they rarely deal with pediatric patients who have a severe disability. The Rehabilitation Institute of Chicago (RIC) offers inservice programs to educate insurance companies about the special needs of children. "We are trying to help the case managers who are accustomed to dealing with adults understand the needs of a 5-year-old paraplegic," says Sheila Hickey, LSW, a social worker at RIC.
• Write letters again and again until you get results. "I write a lot of letters and get the physicians to sign them. We do whatever is going to work. Most of the time, these things eventually get approved, but it takes repeating why the child needs them," Gleeson says.
A mother of a child with a newly acquired spinal cord injury asked the staff at Wisconsin Hospital for Children to write a letter supporting her request that her insurer pay for a hand-pedal bicycle, says Eileen Sherburne, RN MSN CRRN, rehabilitation clinical nurse specialist at the Milwaukee facility. In the letter, she noted the child didn’t use a hospital bed or other equipment typically used by spinal cord injury patients when they are discharged home. She included materials that showed the bicycle would improve the child’s respiratory ability and upper arm strength. The result? A new bicycle for the girl.
• Set up doctor-to-doctor conferences. Gleeson had an insurance company that would not approve a neurologic procedure to allow bladder drainage for young spina bifida patients. The case manager classified it "experimental" because it wasn’t on a list of approved procedures. The child’s physician talked to the insurance company’s medical director and explained the procedure wasn’t on the list simply because it was a pediatric procedure, she says.
• Guide parents in working to solve the problem. A child recovering from meningitis was covered by a health maintenance organization policy with no rehab benefits, Sherburne recalls. The insurer wanted to send the child to a nursing home. The mother argued the policy written for adults discriminated against her child. That argument got the child admitted for inpatient rehabilitation.
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