Insurance Limbo. Medicaid Approves More Hours.

There is just so, so much more to Ryan’s brain injury than caring for him. The paperwork is endless. Legal issues and research, aside from the worthless thugs that caused this, are something that most readers might not think. For example, to simply obtain guardianship of Ryan, we had a lawyer visit our home, file a petition, and have a court hearing. Then… there’s insurance.Insurance Game

Ryan’s therapy visits were approved through last week. As usual, the head therapist came out to do an assessment and submit this for insurance re-approval. We have always heard back within a business day or two. Well, not this time. We are four days out from submission now.

Last week we caught wind that the insurance company was starting to push back on the number of visits. They seem to be taking the position that Ryan is not showing significant cognitive improvement to warrant the current schedule of 3 days each for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). In layman terms:

  • PT = Toes to Waist
  • OT = Waist to Neck
  • ST = Head

The logic by the insurance company has me confused. It really does. My question is, “Do they expect everyone to get smarter from being stretched and ranged?”. When I broke my ankle two summers ago I have no recollection of insurance requiring tests of my cognitive improvements while they rehabilitated my ankle. Why should this be any different for Ryan? He gets PT and OT to maintain and/or improve his physical well-being, with the hopes of cognitive gains as a derivative.

As for ST (which has very little to do with speech, by the way), wouldn’t it be wise to increase the visits? At least to see if it is worthwhile?

I get it. Insurance is in the business to make money. They have risk models. They have algorithms to hedge. They know the odds. If you get right down to it, they are betting you won’t need them… at least not need them beyond a certain threshold. We are betting we will.

Why does it have to be this difficult? Can’t they just deliver what all those premiums were paying them to bet on Ryan’s health? We insured ourselves against catastrophic loss/injury. Like them, we hedged. We hedged even though it was highly unlikely we would need them to this extent. Sadly, we need them to meet their obligation to us now.

Medicaid

Although not where we want to be, Medicaid has approved more hours to pay me for caring for Ryan. They initially agreed 41.5 hours per week. We countered and appealed, asking for the full 84 hours (12 hours a day x 7 days). Meanwhile, no money has exchanged hands.

Really, we weren’t asking for a single minute beyond what I provide. I could argue that, even with a night nurse, we are still “on the clock”. The truth is that the care never stops for us.

Still in appeal, Medicaid has approved 63 hours per week. It looks like they simply split the difference between what they were offering and what I was actually doing.

With that said, I must also say I really appreciate the financial reciprocation. With Jon May and Austin Vantrease (and their families) ignoring their court-ordered retribution, any amount helps a lot.

This leads me to one more thought, which I’ll close on. Why aren’t the Vantrease and May families holding fundraisers to support their sons (and Ryan)?

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kdiviney@ryansrally.org
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24 Responses to Insurance Limbo. Medicaid Approves More Hours.

  1. Jo Hobbs says:

    Ken, if you work more than 40 hours a week, shouldn’t you get paid time-and-a-half or get compensation in some other form like our government workers, union members and others? I’m just sayin’… … Just wait until we hear about the cuts we will all suffer… …also just sayin’ — Still here, older and wiser!

  2. Gail Doyle says:

    Dear Ken, That cartoon was so true:) Why such hassles for getting what’s due you ?There is no amount of money that could be enough for all you do for Ryan…and to have do go through all this on top fo everything else is cruel.May they continue to give you the help of 3 ( should be more ) Days ,or hours ? Always here praying for the healing of Ryan and you to stay well. you’re right those others should have fundraisers just for Ryan. ,Try to keep the faith Ken and things will turn out right. Gail

    • Julie (Ferguson) Commons says:

      Ken, Your son should be eligible for hours with a company called CRI. Community Resources for Independence. Also another may be Center for Indepenedent Living. The Office of Aging may be of help too. My brother had help through them once and was their youngest patient. I realize you have taken on so many other roles other than Dad. It’s extremely exhausting to say the least. If I can help you I certainly would try. My brother has been quadraplegic for near 20 years. He had a head and spinal cord injury. Everyday is a challenge. The tracheostomy, suctioning, fighting pressure sores, therapy, feeding,bathing,dressing, etc.. I son’t need to tell you. Hang in there. You are doing above a great job!

  3. Carla Liberty says:

    Ken,

    When I see and hear and imagine all the things you and Sue do for Ryan, I am left thunderstruck. You’re unwavering love and commitment to Ryan’s well-being is unmatched, and I am in complete awe of your strength and fortitude. Praying with expectancy that the red-tape is snapped and you get everything you need to keep Ryan’s therapy at an optimal level. You are Ryan’s hero. You are a hero to all of us. I send you and your lovely wife a huge hug.

    Love,
    carla

  4. Anna says:

    It amazes me that people can be so cold and heartless as demonstrated by Jonathan May and Austin Vantrease and their families behavior and lack thereof ……I am not sure what to call it, lack of : accountability, compassion shown towards, remorse, helping hand, kindness. No, not even a kind word from any of them to the Diviney’s (Remember Austin’s mom screaming at the hearings at Ken and Ryans friends). I am not sure how these kinds of people live with themselves day in and day out, going about their business. No wonder our society is in the mess it is. We need more parents like Ken and Sue and less like the May and Vantrease parents. Keep up the superior work Ken and Sue, we are there for you!

  5. Dianne says:

    Care and fundraisers come from love. They can’t imagine the love that you, Sue & Kari, and Team Diviney have for our boy, Ryan., If they can’t muster a simple apology to you & Sue, how could they have the heart to have a fundraiser? That’s okay, Team Diviney has more than enough love to give and we’ll put together fundraiser after fundraiser until every penny is covered. Remember, “We Got This”!

  6. Karen S says:

    Ken,

    Insurance and Medicaid. Know that game all too well myself. Insurance is what hassled the doctors who took care of my daughter to push her through the system too quickly. Unfortunately, insurance companies are immune to civil suits (at least in Ohio) so they didn’t have anything to offer except 3 months of homecare and then to shove her onto Medicaid.

    And the two doctors and eight nurses who admitted negligence that ultimately resulted in her brain injury? Well, they aren’t in jail, or paying retribution or anything. In fact, they are doing exactly what they did before they supposedly ‘took care’ of my daughter. Some even received promotions.

    As for Medicaid, when we took care of Kerri, Medicaid wasn’t ‘allowed’ to pay family members for her care. Half the time we had nurses call off and sometimes they didn’t even bother to call or show up. My husband and I still had to work full-time and take care of our other daughter. It was a nightmare.

    We ultimately sued for malpractice and won settlement against the primary physician then continued with a civil suit against OSU. They tried to make us place the original settlement in a Medicaid trust and force the taxpayers to pay when they were self-insured. We fought that b/c they were responsible, and I was afraid about Medicaid cuts which by the way are happening right now in Ohio. Finally, 3 days before trial (which if you sue a state university, your case is heard by a judge (not a jury) who is appointed by the state), they settled with us out of court. But we were in and out of depositions and attorneys for 3 and half years. The mental and emotional anguish is something I never can get past. But I try. At least you get somewhat compensated for taking care of Ryan.

    After 2 years of being medically disabled, Kerri was enrolled in Medicare. Fortunately, my husband’s insurance company still covers Kerri and Medicare is secondary. And she has a trust. So even though sometimes it gets paperwork complicated, I am able to stay home with my daughter and take care of her. But I also have a lot of help now. The most important thing is that I still have my daughter!

  7. Will says:

    With all the cuts coming with Medicaid I say take the hours they offer you now.

  8. Paula says:

    Hello Ken, it sounds to me like what the insurance company is saying is that they don’t think Ryan’s life is worthy enough for them to invest additional therapy. With regard to Ryan’s cognitive improvement, they have no way of knowing with any certainty at all what is happening with Ryan. It is clear to me that Ryan is progressing. The fact that this is not clear to the insurance company tells me that it does not benefit them to give Ryan the benefit of the doubt. As we know, brain injuries are very complex, and it is sometimes difficult to quantify progress. I would think only Ryan’s doctors through the IBRF could make that evaluation with any degree of accuracy. Otherwise, it sounds like the insurance company may be acting in a potentially discriminatory way against a young man who is struggling to get better. Some legal advice may be in order. With regard to the families of the perpetrators of Ryan’s assault, don’t even bother trying to get inside their heads. If they have not had the basic common decency to approach you with offers of help by now, clearly they lack the moral make up to do so. And there is nothing anyone can do about that. After all, how do you think these perpetrators grew to believe that using savage, over the top violence in such a cowardly manner against an innocent person is okay? The values most of us learned were taught to us by our parents. Some of these values include treating others with respect, maintaining our composure in difficult circumstances, apologizing when we are wrong, showing compassion for others, behaving in ways that reflect our values, and refraining from ruthlessly ganging up and inflicting criminal harm on other people. There is an old cliche, “children learn what they live.” The fact that neither set of parents has reached out to you, offered assistance, or in any other way tried to make amends for the egregious acts of their sons, tells me that they are responsible for why their sons lack a moral compass. Unless and until I see these parents do the right thing, I will never be able to think otherwise. To the family of Ryan’s attackers, I will apologize if you prove me wrong. Meanwhile, as the good book says, love covers a multitude of sins, and it is the only and best balm for the wickedness you and your family have suffered. And we’re all sending it to you in the biggest doses we can muster. They may have brutalized Ryan’s body, but they will *never* destroy all that makes him a beautiful and strong soul. On this measure, Ryan will never lose. That’s because he is made of the right stuff. Still praying and still marveling at powerful love your family shows.

  9. Ken, what a huge subject you’ve tried to tackle in a short post. I, like you know that insurance companies are in business to make money but at what cost? The brain is one of the bodies slowest healing organs and all you’re asking for is time (and therapy) to keep Ryan’s body functioning until the brain catches up. Is that to much to ask for after paying outrageous fees for years before this savage attack? After the brain heals, Ryan will ask why he can’t walking or move like he use to? What are you suppost to tell him … “insurance companies wrote you off” … sorry Ryan. Somehow that just doesn’t cut it. I’ve been told I’m to “near sighted” and can’t see the big picture. You’re darn right I’m near sighted. The only case I’m worried about is this one. My insurance case worker cried as she told me insurance wouldn’t cover any more therapies and this is the professionals we pay for. Maybe some of these insurance people ought to “walk a mile in our shoes” and then they’ll see things a little different. This subject gets me steamed up just thinking about it. As for the apology, if it hasn’t happened by now it probably won’t. One of those things you have to let go of (easier said than done) or it WILL drive you crazy. Still praying for Ryan, you and the family in Michigan.

  10. Liz Matson says:

    Is there any legal reason why the thugs can’t be sent a monthly bill for the outstanding retribution due, as well as an itemized accounting of the monthly expenses caused by the beating, both covered and not? I don’t have any delusions that it would be acknowledged orpaid, but it might feel good to send…every single month…

    • Jo Hobbs says:

      Now here’s an idea!!

    • Jill in Morgantown says:

      My thoughts exactly, Liz. As the old saying goes, “you can’t get blood out of a turnip”. But isn’t there some way they could attach wages or something? I know nothing about the legal system and maybe I’m naive, but it seems like there should be something that could be done about this. If Vantrease and/or May have trust funds, perhaps? I don’t know, just rambling I guess. Still here n praying 🙂

    • Anna says:

      GREAT IDEA!!

  11. Milissa Simonsen says:

    Well, they go after dead beat Dads who don’t pay child support by garnishing their wages, their tax returns, putting them in jail, etc. I’m surprised that the court will not order the same for Vantrease and May.

    You are fortunate, Ken, that you are going to get anything for taking care of a family member. I took care of my ex hubby for 2 years for 24 hours a day, 7 days a week, and never got one cent. I lost 2 years of my career and paid thousands to COBRA to keep insurance. I remember the day that I got him out of the hospital. He was put in a wheelchair in a handicapped access van. When we got to my home (it is on about a 35 degree hill), the driver said that he could only drop off at the street. I pushed him up that hill almost losing him and me. When we got into the house, and I transferred him onto the couch, he had urinated on himself, the wheelchair, and then the couch. I just cried at that point. For the next 2 years, it took a toll on my knees, back, and shoulders. You see, he was out of the coma and could speak (he referred to me – his wife – as grandma) and he would scream if I tried to use the machine to transfer. The only shower was upstairs. I took him up one stair at a time on his bottom. I know how hard your days are. I wish I would have reached out to the community for support.

    Those were the hardest days of my life. His life was in my hands. I applaud you.

    • Paula says:

      I am humbled by your sacrifices, and believe the Lord will bless you for everything you’ve done. You’re my kind of hero.

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