We all pay a lot for our health insurance plans and it is amazing how little we understand about our coverage.

Being aware of your insurance plan benefits and care options, preparing for the care and treatment you may need, and being proactive about managing your care and benefits can have a significant impact on your experience when you need to access health and long-term care services. It may also be extremely important to hire a professional to advocate for your needs.

Here’s a true story about a gentleman, who was not aware, prepared, or able to proactively manage his care situation after his surgery and hospital admission. His experience was overwhelming and stressful at a time when it was important for him to focus on his care and get better.

Steve, a 72-year-old male, who has a debilitating lung disease and was recovering from hip surgery, was scheduled for surgery to repair a right shoulder injury. He knew his lung and hip issues were going to impact his post-surgery rehabilitation, but no post-surgery plan was discussed with his doctor. After a successful surgery, Steve’s doctor wanted him to go to the inpatient hospital rehab for intensive therapy.

Unfortunately, Steve’s insurance company denied the doctor’s orders for him to go to the rehab hospital on the day of discharge. His options were to go to a skilled nursing rehab or home with physical therapy services. Steve, who was extremely motivated, did not know what to do. He wanted the best outcome possible and wanted the care his doctor had recommended. Steve needed to decide that day because his insurance would not pay for him to stay another day in the hospital. He was advised to appeal the denial for hospital rehab, but the hospital discharge planner was too busy to help him, and the family did not know what to do.

Fortunately, Steve’s daughter knew a professional Nurse Case Manager who specializes in insurance advocacy. That afternoon, the case manager was able to expedite the appeal to the insurance medical director. That night, the appeal was approved and he was transferred to the hospital’s inpatient rehab unit. He spent two weeks at the rehab and was discharged home with in home nursing, physical therapy and aides services.

The Case Manager continued to advocate for extended nursing, physical therapy, and home aide services until Steve could manage his care on his own. All of his care was covered by his insurance company!

If Steve and his family had been more aware, prepared, and proactive prior to his surgery, his experience could have been very different. Most people do not realize that they can (and should) be more involved with planning their care for short- and long-term healthcare needs. Planning can result in less stress and improved outcomes. What could Steve have done differently?

Prior to the surgery:

  • Ask the surgeon what to expect in the hospital and upon discharge
  • Determine in advance who would advocate for him
  • Share his Advance Directives (Living Will) and Power of Attorney with medical providers and family members, making sure that they are accurate and up to date
  • If acute rehab hospital, skilled nursing, or home care services were recommended, Steve could have asked his doctor’s office or insurance company what would be covered and obtained a list of in-network providers

Post-Surgery:

  • Talk to the Surgeon and Hospital Discharge Planner about discharge options as soon as possible
  • Speak to the therapy team about the optimal location for rehabilitation
  • Determine the best discharge plan based on his doctor’s recommendation and prepared to appeal a denial

To have more control and less stress, you need to be more aware of your insurance benefits and care options. Be prepared to plan for your care needs and be proactive by advocating for the benefits you paid for and the care you deserve. Make sure you always have someone to support and advocate for you if you are unable to care for or represent yourself.

Decrease stress and overwhelm when managing your care and insurance.  Ask for help. There are many resources available to help you. You don’t need to go it alone. Healthcare Pathfinder has experts who provide healthcare advice, advocacy, and management services. Let us focus on your care and insurance so that you can focus on getting better.

Contact Healthcare Pathfinder at either [email protected] or by calling 203-656-2167 for professional and personal advice on planning and preparing for surgery or treatments, advocacy, and managing ongoing claims and medical payments.