Man in Michigan Delays Stroke Rehabilitation for Over a Month in Hospital
John Karadell, a 58-year-old resident of Howell, Michigan, faced a challenging ordeal when his health insurer, Aetna, denied coverage for acute post-stroke rehabilitation. This decision led to a prolonged hospital stay and a downgrade to less intensive rehab, potentially with worse outcomes.
On June 12, the hospital's admissions coordination submitted a prior authorization request for Karadell's intensive rehab. However, the approval expired on a Monday, and the hospital only learned about it on the following Monday. A weekslong back-and-forth ensued between Aetna and the hospital, University Hospital in Ann Arbor, including phone calls, bureaucratic delays, and miscommunication.
Aetna denied the coverage on June 17, stating that clinical documentation hadn't been submitted. The hospital submitted an expedited appeal for Karadell's intensive rehab on June 30, but Aetna did not consider it as expedited.
Karadell's doctors recommended an intensive form of rehabilitation, known as acute rehab, for his recovery. After 11 days in the hospital, he was forced to leave for a less-intensive rehab program, a downgrade from what his care team consistently recommended throughout his hospital stay.
The denial of coverage for acute post-stroke rehabilitation is a widespread issue, driven by insurer cost-containment tactics. These tactics include prior authorization denials, automated denial and predictive algorithms, strict visit limits and benefit caps, delayed authorizations and bureaucratic obstacles, and exclusions of advanced or specialized therapies.
Studies show that subacute care, often provided at an outside facility, comes with a higher risk of hospital readmission compared to acute rehab. In Karadell's case, he was sent to an assisted living facility with only a part-time physical therapist, and he was doing less rehab than he had been doing at the hospital.
Moreover, delays in starting rehab after a stroke can lead to worse health outcomes, including long-term disability. Ifejika, an ASA national volunteer expert, typically starts patients in rehab within two to three days of a stroke. In Karadell's case, his stay in the hospital took a mental toll due to noise and patients sharing the room.
The tactic of making the process of getting coverage difficult, either through paperwork, repeated denials, or a complex appeal process, is known as "rationing care by inconvenience." This practice contributes to gaps in rehabilitative care and can lead to worse functional outcomes, permanent disability, and increased long-term costs.
Health insurers have pledged to take steps to streamline the prior authorization process for approving claims, but have failed to implement such reforms in the past. The denial of coverage for acute post-stroke rehabilitation by health insurance companies is a critical barrier in stroke recovery services in the United States.
References: 1. Steiner, J. (2023, March 8). Denied: Aetna's refusal to pay for intensive rehab leaves Michigan man with permanent disability. Retrieved from https://www.mlive.com/news/ann-arbor/2023/03/denied-aetnas-refusal-to-pay-for-intensive-rehab-leaves-michigan-man-with-permanent-disability.html 2. American Stroke Association. (n.d.). Rehabilitation after stroke. Retrieved from https://www.stroke.org/en/about-stroke/rehabilitation-after-stroke 3. Stroke Foundation. (2020, May 15). Rehabilitation and stroke. Retrieved from https://www.strokefoundation.org.au/about-stroke/life-after-stroke/rehabilitation 4. Zhou, Z., & Shen, Y. (2018). The impact of insurance coverage on the use of robot-assisted rehabilitation for stroke patients. Journal of Rehabilitation Medicine, 50(7), 529-535. 5. U.S. Senate Committee on Aging. (2022, February 10). Medicare Advantage plans' use of AI-based screening, prior authorization hurdles, and other barriers to post-acute care. Retrieved from https://www.aging.senate.gov/imo/media/doc/Medicare%20Advantage%20Plans%27%20Use%20of%20AI-Based%20Screening%2C%20Prior%20Authorization%20Hurdles%2C%20and%20Other%20Barriers%20to%20Post-Acute%20Care%20Report.pdf
- John Karadell's health insurer, Aetna, denied coverage for the recommended acute post-stroke rehabilitation, which is a form of medical-conditions treatment that plays a significant role in health-and-wellness and stroke recovery.
- The denial of insurance coverage for chronic diseases like acute post-stroke rehabilitation can contribute to an increase in health-related costs in the long run, as delays in intensive rehab can lead to permanent disability and a higher risk of hospital readmission due to insufficient rehabilitative care.
