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Thread: Our insurance company wants to cut our RN

  1. #1
    Senior Member okwjoe's Avatar
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    Our insurance company wants to cut our RN

    Hello,
    HealthNet is our insurance carrier I have from work. My son is 20 mos post C4 not on vent. Thet want to take away our nurse because they say he is custoidal care. They say since he is not on a vent, wears a condom cath in the day time, and does not have any monitors he is not need a RN. My son has had several UTI's, bronchitis twice in the past,. We do not know when he gets gets dysrelexic even with the knowledge of the symptoms, he does not display them all the time. hr gets them when constipated, urinary retention, when in pain or when gets spasms. Our nurses have identified several times the periods of dysrelexia and has found the cause. My question when I speak to the case manager how would I say to her to help our argument for a nurse?


    thank you Joe












    h

  2. #2
    Senior Member kate's Avatar
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    Joe, I'm sure others will chime in on this, but my first thought is that you should have the nurses themselves give you written statements about the level of care your son has required. I'd think this would be of some value to an insurance adjustor who probably knows jack about caregiving for a C4 sci patient.

  3. #3
    Quote Originally Posted by okwjoe
    Hello,
    HealthNet is our insurance carrier I have from work. My son is 20 mos post C4 not on vent. Thet want to take away our nurse because they say he is custoidal care. They say since he is not on a vent, wears a condom cath in the day time, and does not have any monitors he is not need a RN. My son has had several UTI's, bronchitis twice in the past,. We do not know when he gets gets dysrelexic even with the knowledge of the symptoms, he does not display them all the time. hr gets them when constipated, urinary retention, when in pain or when gets spasms. Our nurses have identified several times the periods of dysrelexia and has found the cause. My question when I speak to the case manager how would I say to her to help our argument for a nurse?

    thank you Joe

    h
    Joe, I'm assuming your son currently gets nursing care daily right? Is the insurance company going to provide a CNA/PCP to come and help your son with ADLs? If that's the case, they might also provide a nurse on an as needed basis. My bf has a CNA that comes in the morning and at night 7 days a week. Normally a nurse only sees him 2x/month, but if he has a nursing issue, e.g. problem with his catheter, a pressure sore, etc., all he has to do is contact the agency and he can get a nurse to come out until the issue is resolved without a problem. I would ask them about that. Good luck to you guys!

  4. #4
    Most people at his level of injury do not have licensed nurses provided by insurance. Most have PCAs (unlicensed, generally self taught) who follow their direction in giving care. There is no guarantee that an RN will be able to find the cause of AD any better than your son himself (by directing a good PCA to do things). It does not sound like he requires regular skilled care. Are they willing to provide aides (CNA/HHA) or fund a PCA that you hire yourself? Developing care in directing care so that anyone can serve as a PCA is an important skill to learn in rehab and then refine once a person with a high SCI goes home.

    Of course he does need an emergency plan, not just for AD, but for other emergencies. This may need to be being able to call 911 on his own and get paramedic help or be transported to the ER. I would be very surprised if you are able to appeal this decision with the care needs that you describe.

    (KLD)

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