March 2010
Overview of Presentation
Cognitive Rehabilitation Is Medically Necessary Kathy de Domingo, MS, CCC-SLP, Progressive Rehabilitation Associates
What is cognitive rehabilitation?
Who provides cognitive rehabilitation services?
Why is it medically necessary?
“It’s the law!”
So, what’s the problem?
Toolkit (tips and tricks) for advocating for Cog. Rehab. insurance coverage
Laurie Ehlhardt, PhD, CCC-SLP The Teaching Research Institute-Eugene
What is Cognitive Rehabilitation?
Cog Rehab Definition (cont)
Cognitive rehabilitation is a systematically
Treatment goals vary depending on the
applied set of medical and therapeutic services designed to improve cognitive functioning and participation in activities that may be affected by difficulties in one or more cognitive domains. (It) is often part of comprehensive interdisciplinary programs…based upon sound scientific theoretical constructs and strategic approaches…
Cog Rehab Definition (cont) … The overall goal may be restoring function in a cognitive domain or set of domains or teaching compensatory strategies to overcome domain specific problems, improving performance of a specific activity, or generalizing to multiple activities.”
etiology, extent and severity of injury to the brain, the timing of treatment, individual differences, phase of recovery and prospects for restoration or compensation of a problem with remedial interventions. Treatments may be process specific…or skill-based, aimed at improving performance of particular activities…
Examples of Types of Cognitive Rehabilitation (CR)
Executive Functions: Problem-solving & self-monitoring strategies Memory: Training use of external memory aids (ex. diaries, notebooks or PDAs) & strategies (ex. imagery) Attention: Attention process training; strategies training
Communication: Functional communication training (ex.
Task Specific Training (ex. filing tasks; dressing routines) Environmental Modifications (ex. change lighting; decrease
(ex. time management) listening to directions; asking for help)
“Cognitive Rehabilitation: The Evidence, Funding and Case for Advocacy in Brain Injury”, BIA, Nov. 2006
noise)
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March 2010
Who provides CR services?
Certified speech-language pathologists, occupational therapists, vocational rehabilitation counselors, neuropsychologists
May work collectively with patients as part of a team or individually
CAUTION: Some service providers claim expertise in providing these services
Why is CR medically necessary? Case example: Jill is 45 years old. TBI in a car crash. 1-year
post injury; lives at home w/ husband & 2 teen-age children; former school teacher Outpatient CR services at a rehab clinic Moderate-severe cognitive-communication impairments (attention, memory, executive functions); Unsafe in several situations
Case example: Jill (continued)
Why is CR medically necessary?
Not
able to return to work Not safe to take her medications Can’t drive or safely walk across the street Trouble communicating wants/needs when anxious Falls when dressing herself Prone to seizures when overly-fatigued over-stimulating environments
Executive functions :
Why is CR medically necessary?
Why is CR medically necessary?
Memory:
Attention:
Forgets to take her medications.
External memory aid: Trained to use a medication reminder box to cue when she needs to take her pills.
Easily overwhelmed when cooking and can’t self-monitor. Forgets to turn off the burners.
Strategy training: Trained to use a self-monitoring strategy (“StopThink”).
Distracted when crossing the street; at risk for another accident
Attention Process Training (APT): Improves ability to filter out distractions.
Attention strategy: Trained to visually scan in both directions before crossing a street.
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March 2010
Why is CR medically necessary?
Why is CR medically necessary?
Communication:
Fall Risk:
Unable to communicate when fatigued and overwhelmed. Word finding problems. Often leads to angry outbursts and possible seizure.
Functional communication training:
At risk for falls while dressing; unsteady on her feet.
Task specific routine: Trained on a very specific way to do her dressing routine:
Trained to say “I need a break.”
“Step 1. lay out clothes, Step 2. sit down on edge of bed, Step 3….”
Why is CR medically necessary?
Medical Necessity Example policy statement:
General health:
CIGNA covers an individualized program of cognitive rehabilitation as medically necessary following a traumatic brain injury, acute brain insult, or cerebrovascular accident (CVA) when ALL of the following requirements are met:
Prone to fatigue, headaches and sometimes seizures, particularly in noisy, brightly lit, distracting environments.
Environmental modifications: She and her family only go to quiet, dimly lit restaurants. They have scheduled “quiet times” and a quiet room at home.
A documented cognitive impairment with compromised functional status exists. The individual can actively participate in the treatment plan. Significant cognitive improvement is expected and can be demonstrated by documentation submitted on a weekly basis. Interventions should be structured, systematic, goal directed (long- and short-term goals), individualized and restorative.
So, what’s the problem?
Example: Regence Blue Cross/ Blue Shield
Not
all insurance plans have paid for CR services. Why? It’s considered: “investigational” “not medically necessary”
Cognitive Rehabilitation (as a distinct and definable component of the rehabilitation process) is considered investigational for all applicants, including but not limited to: Aging population, including Alzheimer’s patients Multiple sclerosis Post-encaphalitic or post-encaphalopathy patients Stroke Traumatic brain injury
Regence Blue Cross Blue Shield policy, effective 3/1/09
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March 2010
Now it’s the Law! Senate Bill 381 passed in 2009: Requires health benefit plans to provide coverage for medically necessary treatment for traumatic brain injury. Adds orthotic and prosthetic devices to lists of required coverage for health care service contractors and multiple employer welfare arrangements.
Oh, but… What
we don’t know yet….
How
do insurers define “medical necessity”? What about non-traumatic brain injuries?
Toolkit: Policy updates
Toolkit: How do I know if it’s covered?
When
When verifying benefits, ask if the CPT (Current Procedural Terminology) codes associated with the service you will be provided are covered in the member’s policy
If they are covered, ask if there are any associated diagnoses that would negate coverage
last we presented…..
Only Regence and Providence had policies of non-coverage At least 3 had limits on the policy
Now….
Providence reportedly offers coverage Regence has provided clarification and will review again this year Where we see coverage, we are noting more limits (e.g. time since injury limits)
Toolkit: How do I know if it’s covered?
Toolkit: What do I do if it’s not?
Ask
Inform
for access to the company’s coverage policy.
http://blue.regence.com/trgmedpol/alliedHealth/ah20.html
http://www.aetna.com/cpb/medical/data/200_299/0214.html
Ask
if there is a next step in the authorization process – sometimes the initial authorization only means that the case is being authorized for a next level review for appropriateness of services.
your patient of the expectation that the services will not be covered BEFORE you provide the service. Ask the patient or their representative to give you written authorization to receive the services and assume financial responsibility in the event of non-coverage Use your appeal rights!
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March 2010
Toolkit: Internal Appeals/External Claims 1. 2.
3.
Exhaust internal appeals process (appeal to the insurer). If denied on internal appeal, then: Find the external claims (independent) review contact for particular state: http://www.kff.org/consumerguide/7350.cfm A. Contact the Oregon Advocacy Center: 1-800-452-1694 www.oradvocacy.org File external claims. Have supporting documents A.
e.g., documentation of progress, research evidence
Toolkit: Documentation example
Jill X Long term goal: Client will be modified independent in her ability to safely manage her ADL needs Short term goal: 1. Client will demonstrate ability to load pill minder according to prescription and frequency at 100% accuracy. 2. Client use external alarms to take medications as prescribed at 100% accuracy.
Toolkit: How to be your own advocate Provider
advocate for coverage
Documentation is your friend! Ask questions and learn to work within the insurer’s systems.
Toolkit: Documentation Guidelines Medically
necessary
Generally
relates to safety, restoration of lost function, with expectation of improvement as a result of treatment
The
skills of a therapist are required to…
Conduct
an evaluation to determine deficits, residual skills and plan of care Carry out therapy services that are progressive in nature, with continual assessment of progress and barriers to improvement.
Toolkit: Documentation example Correct
vs. Incorrect example. You choose:
Client will do “Brain Train” exercises Client will improve ability to perform tasks demanding moderately complex visual and/or auditory attention skills to 80% accuracy.
Toolkit: How to be your own advocate Survivor
advocate for access to services
Know your insurance policy and your rights to appeal Ask for assistance from case management Don’t take the first “no” you hear. Ask if there are more steps available to you. Look for external advocates Provider you are working with Brain Injury Association Disability Rights Oregon
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March 2010
Resources Brain
Injury Association of Oregon
www.biaoregon.org 1-800-544-5243
Disability
Rights Oregon
www.disabilityrightsoregon.org 1-800-452-1694
See manual with examples “Finding and using resources”
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