Getting the Most Therapy Coverage

Stroke survivors can almost always benefit from more therapy (physical, speech, occupational), but most insurers limit the amount of therapy coverage. Getting more therapy is not as simple as asking nicely. You must understand your insurance benefits and discuss them knowledgeably with your insurer, their Utilization Review Nurse (URN) and your rehab provider.

Maximizing Your Rehab and Recovery

Since rehabilitation coverage is limited, make sure you maximize your therapy while you have good insurance coverage. Here are some considerations to maximize your therapy:

• Work hard to continue the best outcomes. If you’re making progress in therapy, you may be able to continue if you get authorization from your insurance provider. Authorization is only granted when consistent progress has been achieved and documented by your rehab provider. Discuss your progress with your therapy team and follow your treatment plan. Compliance can affect your progress. Always ask for copies of the documentation.
• Ask your therapist for a home plan. A home therapy plan often helps maximize your results and therapy. Stroke recovery is a lifelong effort. Diligence in working on home rehabilitation is important.
• If you can afford it, consider out-of-pocket rehabilitation to continue your therapy. Some insurance companies have a set dollar amount for rehabilitation therapy. If you’re in therapy and you want to continue past your policy’s cutoff, talk to your therapist and doctor and expect out-of pocket costs.
• Be proactive if you’re not meeting your goals. If you believe your rehab is inadequate, talk to your doctor about transferring to a new provider.

A Change in Your Condition

If you’re not in therapy, but have noticed a change — positive or negative — in mobility or speech, talk to your doctor about getting more therapy. Your doctor must validate changes in your condition and prescribe additional rehab — if it’s medically necessary. Medical necessity must meet one of these standards:

• The service is expected to prevent the onset of an illness, condition or disability.
• The service is expected to reduce the physical, mental or developmental effects of an illness, condition or disability.
• The service will help the person achieve or maintain maximum functional capacity in performing daily activities.

Once rehab is authorized, you may participate until maximum medical improvement has been achieved. Services stop when progress stops. Again, make sure your provider is documenting your progress and ask for a copy. Whenever you or your caregiver see a change in your functional ability, get re-evaluated by your rehab doctor or therapist. Functional abilities include selfcare skills such as feeding, dressing and grooming as well as transfers, walking and wheelchair skills. If your caregiver is having more difficulty helping you, that may meet the standard for more therapy.

Work with Your Insurer’s Review Nurse

Create an ally in your Utilization Review Nurse, who works for your insurance company to control overuse of services, reduce costs and manage care. The URN reviews bills and records and discusses your case with your provider. That’s why documentation is so important.

Insurers follow protocols to determine overuse of care. An insurer may refuse to reimburse for services when they don’t meet those standards. Your URN will know and understand those protocols. He or she may determine other areas of your policy that can cover services once the rehab portion is used up. Insurers make exceptions under specific circumstances. URNs know the rules. They can guide you in getting the right documentation.

Source: Excerpted and adapted from the American Stroke Association’s Finances After Stroke Guide, free downloadable PDF available.