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Finding the Best Care for a Loved One in a Coma 

 Legal and Financial Issues

Case Managers

A basic guide to the different legal and financial issues facing the family of a brain-injured person.

I am a speech pathologist who works with TBI. I have worked in a variety of settings over the past 13 yrs, and have seen the HMO's take over healthcare. Don't ever be deceived into thinking your doctor can determine the course of your loved one's medical care. It is in the hands of the insurance company. Some of these insurance networks are set up so that the doctor is given X amount of dollars each month for each patient. If that person stays well and doesn't see the doctor, the doctor pockets that money. If the person has to come in for a visit, and tests need to be run, the doctor loses that money. Of course, there are many ethical docs out there but they are being squeezed by the system.

I do post-acute care with most mild brain injuries. I can't even get funding from most HMO's or private insurance companies, thus most of my practice is made up of worker's compensation. And don't think the providers are getting rich, either. When I call a private insurance company to find out about a new patient's benefits, I am usually told that they will pay 70 or 80% of the "usual and customary rate".

They won't tell me what that rate is. And legally I am not allowed to call other speech pathologists in town and find out what they charge because that would be considered collusion or price fixing. So every patient I treat with private insurance is a gamble for me. I don't get paid until 2 or 3 months after I provide the treatment and I have no idea how much I will be reimbursed. Crazy way to try to make a living, huh? But I love my work. I have met so many wonderful people over the years from every walk of life.

This may help some of you to get your loved one into a rehab program if you have private insurance or an HMO: You can ask the insurance company to assign a case manager to your loved one's case. That gets you out of the narrow confines of the policy, because a case manager can trade benefits around. What I mean is, if there is a benefit in your policy that it is likely will never be needed, they can use the dollars from that portion of the policy to pay for something like a rehab program that is otherwise not expressly covered by the policy. A claims adjuster can't do that. Ask that your loved one's case be moved into case management. Not all insurance companies will do this.



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Attorney Gordon S. Johnson, Jr.

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