Once the acute care period is over and the patient is stabilized, the resources available to the patient can substantially impact treatment and recovery. In a perfect world, every patient would have unlimited access to the best resources available to meet their needs. Ours unfortunately is not a perfect world.

The consequences of a traumatic brain injury are far reaching. Not only are there treatment costs associated with the recovery from the acute injuries, but there are the costs of long term care and supervision, the lost support to the family unit that the injured party previously contributed, the increased physical demands placed upon the caregivers and family of the survivor to meet the needs of their injured loved ones, and the family having to step into the breach of the role that the injured person previously contributed to the family.

This analysis will focus on health insurance sources of funding for treatment and assistance to the traumatically brain injured.

Secondary Payors stand behind the patient to pay all or a portion of the patient’s medical expenses depending upon coverage and policy limitations. Healthcare providers are familiar with the process of confirming coverage in advance of medical procedures and I will not be addressing those issues here. Also, I will not address appeals from denial of coverage for medical procedures as those appeals are often dependent upon the precise language of the policy and the parties involved in the decision making process.

A.Health Insurance Coverage

The health insurance coverage which a patient has can make a dramatic difference in the care which is available to the patient who is unable or unwilling to pay for the services directly. The type of insurance the patient has becomes most noticeable once the patient has stabilized.

1.Lifetime Coverage Limits

Most insurance companies have insurance policies that establish lifetime limits on coverage. Be aware that procedures which are covered may become uncovered once the lifetime limit has been reached. It is not uncommon for lifetime limits to be reached in treating catastrophic injuries. Families and treating medical professionals should be aware of the impact of their patient’s lifetime limit coverage limits and request threshold notification from the insurance provider as the threshold of the coverage limitation is approached.

2.Subrogation Clauses

Subrogation clauses appear in some insurance policies. A subrogation clause allows the insurer the right to take legal action against a third party responsible for a loss to an insured for which a claim has been paid. The clause takes its name from the section of the policy which gives the insurer the right to be subrogated to, or take as its own, the insured’s claim and to sue the person or entity causing the injuries for the damages. An insurance carrier may only sue in the name of the insured if the insured had a deductible and therefore a personal stake in the outcome of the litigation. Few health insurance policies have true subrogation clauses.

3.Therapy Benefits

Policies often have different caps and coverage’s for therapy benefits. Coverage’s for therapy benefits need to be explored and the therapy services properly coded in order to insure reimbursement for these much needed modalities.

4.Home Care Benefits

If a patient has long term care insurance, that will often cover home care benefits. Long term care insurance benefits, while often purchased by the elderly, apply to all persons meeting the coverage definitions. Traumatically brain injured individuals often meet the coverage definitions of long term care insurance benefits.

5.Veterans Administration Benefits

If your patient was in the military, and certain covered spouses, they may be entitled to Veterans Administration benefits. The Veterans Administration contracts with some nursing homes to provide for residents covered by the VA Program.

6.Durable Medical Equipment

There is often separate coverage under most policies for the provision of durable medical equipment.

Traumatic Brain Injuries are often referred to as the silent epidemic. A person’s life can be substantially and dramatically affected by a brain injury. Those of you serving on the front lines want the best outcome for their patients and loved ones. By securing all available funding, our loved ones can focus on their recovery.