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Thread: Recent Accident to My Son

  1. #41
    1. Santa Clara lost their model standing
    2. UCLA is not CARF accredited


    Keep pushing back at them, you will win as will your son.
    Every day I wake up is a good one

  2. #42
    Senior Member
    Join Date
    Nov 2003
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    Suburb Near Chicago
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    754

    Thumbs up

    Might I reccomend The Rehabilitation Institute Of Chicago.

    Hell, they are the number rated spinal cord rehabilitation center in the nation for 16 years now.

    I went there and it was excellent. I would check it out.

    www.ric.org

    Eddie
    -----------
    Eddie

  3. #43

    Good letter

    I thought he wrote a good letter. He used the statswell. Ask him to get stats for low rehospitilazations and secondary conditions. Shepherd can give thta to you. I am certain BC/BS steered you towards Shepherd because Craig asks for a guaranteed 90 days.

    The doctor might want add things like, "In my medical opinion, etc. Also, there is a PVA handbook on SCI outcomes. Let me look and see what I can locate. If I find something, I can email it to you.

    Is his employeer willing to take him back? Let them stress quality of rehab and desire to bring employee back. I have seen large companies threaten to pul from BC/BS because of one patient and rehab. It has worked.
    Every day I wake up is a good one

  4. #44

    Clinical Guidelines

    Here are some clinical guidelines and outcomes from PVA, this is for the professional. Might want to use the info to battle the insurance company. They are free to download at pva.org
    Every day I wake up is a good one

  5. #45
    Senior Member
    Join Date
    Feb 2007
    Location
    Phoenix AZ
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    633
    Cheesecake

    Brian's employer wants him back. Blue Shield is not steering Brian toward Shepherd. We want to go to Shepherd but Blue Shield has denied authorization. The Blue Shield doctor on the review board wants Brian to go to Santa Clara or UCLA. We want him to go to Shepherd. Brian's Blue Shield insurance is a PPO plan. The first Blue Sheild case worker told us we could go to whatever rehab facility that we wanted. Now the second Blue Sheild case worker is saying that Blue Sheild has to give us authorization.

    Roger

  6. #46
    Quote Originally Posted by Roger
    Cheesecake

    Brian's employer wants him back. Blue Shield is not steering Brian toward Shepherd. We want to go to Shepherd but Blue Shield has denied authorization. The Blue Shield doctor on the review board wants Brian to go to Santa Clara or UCLA. We want him to go to Shepherd. Brian's Blue Shield insurance is a PPO plan. The first Blue Sheild case worker told us we could go to whatever rehab facility that we wanted. Now the second Blue Sheild case worker is saying that Blue Sheild has to give us authorization.

    Roger
    Push back. The doctor wrote a strong letter, ask him to tighten it a bit if necesary. Again, UCLA does not have CARF accredidation for SCI and Santa Clara lost their Model SCI center standing. If necessary, take it to the CA Insurance Commission. Refuse transfer to CA if necessary. Shepherd is an excellent Center, the insurance company can pay now or pay later, the reality is good rehab will benefit him now and in the long run. The folks at Shepehd are also good at helping get the certification.
    Good luck and email me if you need help.

    Hopsitilization may need to be aproved, even with a PPO as this will fall into major medical.
    Every day I wake up is a good one

  7. #47
    UCLA has no CARF accredited rehab programs at all....not even general rehab. Santa Clara Valley is no longer a Model SCI System Center, and is a county hospital...and not what it used to be either, but certainly better than UCLA.

    If you must stick to CA, then either Rancho Los Amigos National Rehab Hospital in Downey or Casa Colina in Pomona would be my choices.

    Craig (Denver) is fine too, and probably equal to Shepherd. Would they let you go there?

    Is this BC/BS doctor a physiatrist? If not, ask that the authorization be reviewed by a physiatrist (a specialist in physical medicine and rehab) not just an orthopedist or neurosurgeon who is NOT a rehab specialist. it doesn't sound like this doctor knows anything about rehab centers except the ones they want to pay for.

    I would second talking to the people at Shepherd (or Craig) as they are experienced in helping convince insurances to use their programs.

    It may be too late to get a copy of this free book, but you could call the author's law office and they will help as well:

    http://www.josephromanolaw.com/

    Keep pushing. Don't give up!

    (KLD)

  8. #48
    Senior Member
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    Cheesecake

    I wrote the letter and then sent it to some people at Shepherd for their comments. Monday morning I'm going to try and catch Dr Theodore and ask him if he'll present my letter or an edited version of it to Blue Shield.

    Roger

  9. #49

    Telephoen appeal

    Roger~
    KLD gave excellent advice about being sure the BC/BS doctor is a physiatrist. Also, ask to take part in any telephone appeal that might occur.
    Rancho lost its Model facility designation and is also a county hospital like Santa Clara. Keep your focus on Shepherd and don't back down. Ask where in the policy it states they can select the facility. Generally Shepherd and Craig are centers of excellence for mos policies. Push for the access to care, it will help Brian in the long run.

    This is a difficult phase, you will get through it and Brian will see the benefits. Don't discourage and be persistant. Remember that the insurance policy is a contract and the contract is binding.

    If his employeers HR folks chime in with BC/BS, it will have an impact. They bought a product and want the best for their employees, use that avenue as well.

    Good luck and keep us posted.
    Every day I wake up is a good one

  10. #50

    Exclamation

    Any good news Roger? Been thinking of you and Brian today.
    Every day I wake up is a good one

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