What To Do If Your Aging Parent Is Denied Rehab

[ photo by Liza Summer ]

Acute rehab denials.

As a physician in rehabilitation medicine, working the majority of my career in inpatient rehabilitation, I have a lot of experience with dealing with the insurance side of things in regards to how long a patient can stay in rehab and what level of rehabilitation is the most appropriate.

I remember during my residency training hearing my attending doctors tell me about patients they had in the past that would be able to stay for multiple months receiving inpatient rehab following a life-altering medical illness such as a stroke or spinal cord injury. During my residency training, those stays were shorter, for sure, but they seemed to still be on the longer side, at least to the length in which patients and their family members felt a bit more comfortable bringing their loved one home.

(Related blog post: Taking Care Of Elderly Parents At Home)

Rehab lengths of stay are getting shorter.

As my career has progressed, I have found the lengths of stay have continued to shorten. I have written about what to expect in the past in regards to how long one might stay in acute rehab based on the reason for admission. These lengths of stay are changing, however. They are becoming less predictable. 

(Related blog post: Acute Rehabilitation Versus Subacute Rehabilitation: What’s The Difference?)

What I want to be clear on in this ever-changing world of rehabilitation is that much of this is driven by the insurance companies. For those with private insurance or some sort of medicare advantage plan, the physicians will make the recommendation for admission to inpatient rehabilitation, but the insurance company gets the final say as to whether or not someone will be approved to go to inpatient rehabilitation.

Once your aging parent is admitted to inpatient rehab, I wish I could tell you that your rehabilitation team, made up of the physiatrist, therapists (physical, occupational, and speech), psychologist, nurse and case manager, get to drive the ship until the team recommendation of discharge date and location is determined. Unfortunately, that is not exactly the case. Our team is able to make our recommendation, but the final determination of how long someone stays in rehabilitation is made by your loved one’s insurance company. 

What to do if your aging parent is denied rehab.

Now, I want to cover what to do if that initial request for inpatient rehabilitation, acute or subacute, gets denied. Generally, the first thing that happens is an appeal is made. This might initially require the treating facility to send additional documentation of your parent’s stay, with focus on the therapists’ notes and the physicians’ notes.

The documents are then reviewed again, usually by a physician working for the insurance company. Unfortunately, it is becoming much more common for these to be denied, and the case moves to a peer to peer review. The peer to peer review involves your parent’s primary treating physician to discuss the case with a physician within the insurance company. The hope is that the physician within the insurance company is a board certified physical medicine and rehabilitation physician, but this does not always happen. I have been the physician appealing for an extension of stay in the inpatient rehabilitation setting. Despite my efforts, I have lost more of these appeals than I have won. In my discussion with other fellow rehabilitation physicians, they usually report similar results. 

So what’s next? What do you do if you know your loved one needs more inpatient rehab? And in some increasingly more common instances, not just needs more rehab but needs even an initial admission to a rehabilitation facility?

Submit a family appeal.

There is another lesser known step you can take as a family member. The other option that is not often pursued is the family appeal. This generally requires a phone call from the family member to the insurance company on your loved one’s behalf to determine what steps need to be taken to arrange this particular appeal.

The family appeal is a bit unconventional, however, these tend to be more successful than the physician to physician (peer to peer) reviews. You know that no one will fight harder for your parent than you. It is also often harder for someone with the insurance company to say no to services to a family member of a loved one than to another physician. 

Navigating the rehabilitation process of your aging parent can be tricky, time consuming, and frustrating! Hopefully this one little tip might give your loved one a better chance to undergo more inpatient rehabilitation than he or she might have otherwise been able to have.

Feeling overwhelmed with the process?

Afraid you may not make the right decision at the right time? This stage of life for you and your aging parent often brings more questions than answers. Reading information from a trusted source like me can help guide you in the process. However, if you still feel overwhelmed, don’t hesitate to reach out to me. I am happy to help with a personalized plan for your unique situation.

© 2022 Jessica Kluetz, DO