How Long-Term Hospital-Level Care Can Help You Make a Full RecoveryHow Long-Term Hospital-Level Care Can Help You Make a Full Recovery
If you or a loved one has suffered a serious injury, illness, or surgery, it’s likely that you’ll need additional care to fully recover after being discharged from the hospital. In this case, your doctor will refer you to a long-term acute care hospital (LTACH). At AMG, you’ll often hear an LTACH referred to as a critical illness recovery hospital. A critical illness recovery hospital can help you get the hospital-level care and rehabilitation services needed to regain more of your independence and reduce the chance that you’ll return to the hospital. But what do you do if your LTACH referral is denied by your insurance provider?
Unfortunately, it is possible that your insurance company could deny your LTACH referral. This can be frustrating and confusing when both you and your doctor know that you need additional care. Learn more about what you can do if your insurance provider has denied long-term acute care hospital services with AMG.
LTACHs vs. Traditional Hospitals
First, you should know what an LTACH is and how it compares to a regular hospital. Many people confuse an LTACH with a long-term care facility or nursing home. However, this could not be farther from the truth.
An LTACH is equipped to provide the same intensity of care and intervention that you get in the intensive care unit of a traditional hospital. Of course, there are some key differences between an LTACH and a traditional hospital.
The first difference is that a traditional hospital treats immediate medical needs, but keeping patients for an extended period of time is not possible. For example, if you have a stroke, a regular hospital will generally discharge you within five to seven days. You might be out of danger at this point, but a full recovery could be much farther away.
An LTACH, on the other hand, provides the same 24-hour nursing and daily specialist access that you received during your emergency admission to the hospital. But the LTACH provides the extended critical care and specialized rehabilitation therapies essential for your long-term recovery.
Another difference between an LTACH and a regular hospital is the number of conditions they treat. A regular hospital treats a very broad range of conditions, ranging from minor injuries to life-threatening diseases. However, our critical illness recovery hospitals specialize in treating patients who require care for several weeks.
Why an LTACH Referral May Be Denied by Insurance Providers
Sometimes, an LTACH referral may be denied by insurance companies. There may be several reasons why a referral was denied, including:
- Preadmission screenings – We conduct a preadmission screening for all of our patients. Included within the screening is a patient history, an assessment of current conditions, an overview of the patient’s diagnosis, and the patient’s needs for an LTACH. Sometimes the insurance company will disagree with this assessment and deny the referral.
- Out of network – Your insurance may also have an “in-network provider.” If the LTACH you choose is not included in this list, your referral could be denied initially.
- Lack of plan benefits – While most insurance plans cover a medically necessary stay in an LTACH, it is possible that your plan isn’t one of them. In this case, we can often help you navigate an appeal.
- Unlikely chance of recovery – Your doctor will only refer you to an LTACH if you need more time to recover or move to another level of care. If your insurance feels this isn’t accurate, they will deny the referral.
How To Get the Care You Need After Your Referral Was Denied
Your health condition is stressful enough — don’t let your insurance company stress you out any more than you already are.
Thankfully, LTACH admission process professionals at AMG can coordinate with your doctor, hospital, and insurance to understand the reason behind your denial and work to get your care back on track.
While we handle the heavy lifting, there are a few things that you can do to help accelerate the process:
1. Call Your Insurance Company
The first step in overcoming your referral’s denial is to find out the reason for it. The easiest way to do that is simply to pick up the phone. Once you’re armed with the knowledge of why you’ve been denied, you’re better able to advocate for the care that you need.
2. Talk To Your Doctor
Ask your doctor to explain why they recommended the LTACH and to provide a letter of medical necessity. This letter should detail why the care you need cannot be met by other in-network providers.
3. File an Appeal
Depending on the type of insurance you have, there is a specific process for appealing LTACH insurance denial that you’ll need to follow. For private insurance, there are two levels of appeals. The first is an internal appeal, which is handled by the insurance company. The second is an external process reviewed by a third party. If you have Medicare, there are five levels of appeal where the denial can be overturned. Medicare also offers a fast appeal process if you feel you’re being discharged from the hospital too soon.
4. Ask for an Exception
If the denial is a result of the LTACH being out-of-network, you can always ask for an exception to be made. This can be helpful if you have a medical necessity that the current providers in your plan aren’t able to meet.
5. Keep a Paper Trail
Keep every letter you get from your insurance company, copies of your appeals, as well as notes on dates that you speak to someone at the company, their name, and anything you learned.
6. Collect Your Evidence
You should also collect your hospital records, doctors’ notes, lab and imaging reports, and prescriptions. This helps support medical necessity.
7. Reach Out To Your State Insurance Department
If all else fails, your state insurance department and the attorney general can often help advocate for you.
If you’re feeling overwhelmed and don’t know where to start, be sure to reach out to the case managers at AMG for help.
Recover at Your Own Pace
At AMG Specialty Hospital, we’re here to help. We know how confusing and intimidating it can be to navigate the referral process when you or your loved one has already been through so much.
From the moment you’re referred to one of our locations, we’ll work to help you. We will conduct a complete review of your coverage to ensure that you have benefits. Additionally, we’ll work to overcome any insurance barriers you might face prior to admission. Our team of knowledgeable professionals will help you every step of the process.
We’re dedicated to getting you the care you need to recover more fully and regain your highest level of independence and quality of life. Schedule a tour or contact your nearest AMG location today to learn more about how we can help you with your denied LTACH referral.
