Bo Yennie has made significant progress in regaining some of the independence he lost after suffering a spinal injury in a severe ski crash at Steamboat, and is confident he can make more with continued work.
But his insurance company believes he no longer needs to be in the nursing home where he receives physical and occupational therapy, which could force him to stop working on his recovery early.
Yennie’s family home is in rural Routt County, and traveling to a physical therapy center or finding someone willing to make frequent house calls is unfeasible, his son Ben Yennie said.
Yennie has a insurance plan through the . Medicare, including Advantage plans, covers up to 100 days of rehabilitation care following a significant injury or illness, if medically necessary. He started care on March 4.
But United made it increasingly difficult to get that care, requiring the family to get reauthorization every two days for Yennie to stay at Lemay Avenue Health & Rehab in Fort Collins, Ben Yennie said.
On April 10, after paying for about five weeks, United determined Yennie no longer needed residential care, forcing the family to pay out-of-pocket during the appeals process, he said.
About 99% of people in Medicare Advantage must get prior authorization for at least some services, typically high-cost ones such as nursing home care or non-emergency hospital admissions, .
Insurance companies say that prior authorization and reauthorizations as treatment progresses ensure that patients are getting the right level of care, while consumer groups see them as a way for insurers to save money by denying services patients need — or by adding enough hassles that they give up. Most authorizations ultimately go through, particularly if patients appeal.
In his appeal, Ben Yennie said his father’s and he requires treatment to raise it long enough to participate in physical therapy. It wouldn’t be safe for him to get that treatment in a setting without providers monitoring him before his sessions, he said.
They learned Wednesday that they won their appeal, meaning United will reimburse the family for their out-of-pocket spending, but another reauthorization is coming up. Ben Yennie said the company plans to review his father’s care again Thursday, meaning the appeals process could start again if it recommends discharging him.
Paying out-of-pocket for a $20,000-per-month nursing facility isn’t feasible for long, he said.
“He was a public school teacher. There’s only so much there,” he said.
United Healthcare released a statement saying that it conducts reviews to ensure plan members are getting the right care, using “peer-to-peer” conversations with providers and facilities. How often a patient’s care comes up for review depends on how complex their condition is and how it has evolved.
“We understand how difficult recovery and transitions between different levels of care can be for patients and families, especially following a serious injury. Our goal is to support members in accessing coverage for the right care, in the right setting, for the best possible recovery and health outcomes, following evidence‑based care to support that goal,” the statement said.
Kylie Thompson, social services director at Lemay, said insurance companies typically require more frequent reviews as a patient’s stay goes on, to ensure they’re still making progress, but not well enough to move to another setting. Part of her job is to help patients and their families understand their rights and navigate the process, she said.
In most cases, a review is just a phone call, but families want to focus on their loved one’s recovery and may get nervous that someone they don’t know is deciding on the person’s care, Thompson said.
“The process is not difficult… but it can be emotionally taxing,” she said. “Everything is on the line for that phone call.”
Insurers see requiring prior authorization and periodic reviews as a way to produce savings, but given the high percentage of care that they approve initially or following an appeal, no one knows if they’ve succeeded in that regard, said Adam Fox, deputy director of the .
A study found independent review organizations if the patient appealed, at least in New York.
“A lot of this is creating a huge amount of busywork,” he said.
A separate study estimated the average prior authorization request — significant, when added up over tens of thousands of customers, but far less expensive than the care patients are seeking in most cases. Since only a small percentage of people appeal their denials, insurers likely have savings in the short term, though those may not last if people experience complications from discharging too early, Fox said.
“They’re sort of gambling on that someone released early is not going to have additional care needs,” he said.
People can reduce their chances of disruption from insurance authorization by working closely with their medical providers, who are often the ones submitting the paperwork, Fox said. Everyone has a right to appeal a decision that went against them, but not to challenge how often the insurer requires reauthorization, he said.
Yennie said he has improved significantly since January, when he went over an unmarked ledge while skiing at Steamboat, essentially bruising his spinal cord in the crash. In the immediate aftermath of the accident, he could wiggle his toes, but couldn’t get his abdominal muscles to contract, which prevented him from sitting up without help. Other muscles over-contracted, pulling his arms in toward his body.
The doctors don’t know how much function he’ll regain, but they’ve warned him to expect a long process of physical therapy, Yennie said. He’s talked to people with similar injuries who aren’t back at baseline five years out, but continue making incremental progress.
At the moment, he’s working on transferring from his bed to a motorized wheelchair, as well as performing daily activities such as shaving and brushing his teeth. He needs to reach a point where he can get out of bed with only one person’s help before moving to a step-down facility, Yennie said.
“I’m not there yet, but I’m working on it,” he said.
His physical and occupational therapists have canceled sessions at times because of uncertainty about whether insurance would pay, Yennie said. United Healthcare initially reviewed his care after a week, then after four days and then after two days. He thinks the company is trying to wear him down.
“I don’t know what a person would do without advocates,” he said.
