BCBS of NJ denying Acute Care

Hey Reddit what are my options? I feel like I’m at wit’s end and just frustrated. We did what we were supposed to do and have just gotten screwed for it. Problems and full timeline below.

Horizon BCBS NJ is denying Acute Rehab for a family stroke patient and we have exhausted our appeals which translates to two peer to peer appeals. We currently have two different issues.

We can’t get insurance to send him to acute rehab at the Brain Trauma Unit in the hospital a few weeks after they sent him to a borderline negligent subacute vent facility. He’s at the hospital now while discharged after putting a piece of his skull back in.

He was asleep his first 30 days in the hospital. The day after he was sent to the weaning facility was the day he woke up. The subacute facility delayed his vent weaning timeline and they performed very little rehab if any. I would bet a considerable amount of money they actually lied about the amount and quality of rehab given. After three weeks their insurance denied further coverage despite the family having a list of progress examples he has made.

I knew he had the follow up surgery to put back the skull piece and just hoped that the hospital sees the progress he’s made and would place him into acute rehab here. The hospital agreed, but insurance did not approve it and we haven’t received the letter explaining why. We think it was because of the “unsatisfactory progress” he made at the other facility since they sent a letter saying he was 100% dependent after denying coverage at the subacute facility. We don’t even know what that means so we can’t even argue against that.

It’s crazy to me since the first three months are when patients are expected to make the most recovery and it seems like insurance literally does not care and sent him to a place that did not help, and will now not send him to a place that would help.

I could understand them “tightening the belt” after the three months he was supposed to make progress in, but after three weeks? They now are counter offering a subacute facility which is where he just was despite me thinking he was never given a chance at full rehab and we’re almost 90 days out. And they might just deny coverage after he’s there for a week. Why wouldn’t they? What recourse would we have?

There are similar patients who are paralyzed on their left sides in the BTU.

2. We also are getting told two different things by supposedly the same insurance plan. The local union plan is telling us they don’t do pre-authorizations and HORIZON BCBS is only supposed to price the medical services since the local plan is self funded.

Yet we can’t get the hospital to just send him to the rehab unit because they only deal with pre-authorizations. I’ve tried contacting BCBS but I just get punted to the same local union plan employees who tell me to just send him to that acute facility.

We haven’t been able to contact anyone at BCBS who is making these decisions besides the social worker (not helpful) and now we have a number that goes right to voicemail for the appeals.

So is the local union rep of the medical insurance on the back of his card wrong? Why would they make up such specific claims?

Patients timeline.

Late-Feb They suffered a stroke.

In the hospital semi-unconscious for 30 days slowly weaning to the point that he was going to get the trach collar the day he left. He didn’t make progress because he was asleep unusually long I guess.

Early-April went to the subacute facility for 30 days. And it took three weeks to start trach collar. Pretty sure they were negligent about making progress. (Maybe we should get a lawyer for this)

Mid May He went to the hospital to surgically put his skull back in. Hospital has requested to send him to acute rehab with two peer to peer appeals and has been denied both times.

Now we are just trying to explore options because we think this whole thing is BS.

What are our options? Is this a post on twitter situation? Do we try and email back any email we have with the information we have?

Is my family member just fucked?