I have recently came across a case of a patient in coma who was also pregnant. Although she was initially in a coma state, eventually she came out of it and started to move with visible volition at several levels. At this point the insurance coverage will end for her rehabilitation. I wonder in general how patients in the US cope with coma states (i.e. how the relatives do this?) and how is it in relation to other nations of the European Union or Canada where insurance coverage is different?
http://journal.frontiersin.org/article/10.3389/fnhum.2015.00128/abstract
Article Objective and personalized longitudinal assessment of a preg...
Hi Elizabeth,
In the US this is very insurance-specific. There is no universally accepted criteria for covering coma states, and to what extent.Some insurers may, in fact, subject the treatment to medical management review, while others may simply cover it as part of the hospital stay. The extended stay may raise issues between the insurer and hospital over payment, where the hospital may want additional payment beyond the DRG, or per-diem. That would likely be an internal issue between the payor and hospital, however, and the family may not be aware of the wrangling behind the scenes (unless, of course, the deductable has not been met yet, and thus the patient/family will be very much aware of the costs).
I hope this helps
Ariel
Thanks Ariel, This helps a lot
Do you know what type of evidence the insurance companies use to make the decision as to whether or not to send the person to rehab in a different center? and then once in rehab out of the hospital, how do they determine if the person is improving or not with the rehab?
Medical management decisions are a "black-box" phenomenon at best. The review may first be conducted by an RN, then sent to an MD if the clinical issues are complex. The MD will rely on clinical judgment and render a verdict. This can then be appealed by the patient/provider, usually with the provision of additional information. If the insurer again denies coverage, this can be further appealed by an outside arbiter. Ultimately, a lawsuit may ensue if the denial is continuously upheld.
Thanks!
The person that I am in contact with is really improving by the day but her insurance coverage will be cut off soon and the family will have to cover everything from that point on. Some anonymous donors have raised funds for this coverage because the case gained some interest in the Fresno area but those funds will run out very soon as the therapies are very expensive.
Thanks for your information. It is very useful. I came across insurance coverage issues before in the field of autism where parents beg for sensory-motor integration OT and PT therapies but none of it is covered. Public schools have some of it but they is very useless to the kids. Anyhow, this case is a completely different scenario (life or dead issues involved) but just as bad. I wonder how other nations cope with these problems.
thanks again for your input
very few people know about these issues as it is hard to navigate the maze of complex forms, red tape and people making decisions for your loved ones (very frustrating system in the US)
Indeed, this health system is fraught with problems and provides little transparency. I could write a book on all the problems, but it would be the size of a dictionary!
Good luck!
Ariel
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