You’ve received a referral to evaluate a person who has suffered an acquired brain injury.  Maybe it’s the result of an assault, motor vehicle accident, an anoxic event, a fall, or an arterial venous malformation, or some other accident or illness that led to the persisting cognitive communication deficits that the person and his or her family continue to struggle with.  Let’s make this a little more fun…..you’re in an outpatient setting and the funding source is a major medical provider or a major insurance company, or, even better, motor vehicle insurance with the personal injury protection (PIP) allowance nearly exhausted.  If you work in an inpatient setting, this funding issue may not make much sense to you, but if you are in outpatient, it’s probably all too familiar.

The challenges are many in this scenario.  Even if the injury was a mild one, ask the person and their family and they’ll tell you that they are still greatly disruptive to their lives and well being.  As I heard in a recent conversation with a survivor, “Same old problems, new brain functioning.”  This person is a couple of years out from his rehabilitation, so he’s had time to habituate the new habits he’s had to learn to cope with those same old problems.  Speed of processing and effort required to solve those old problems are far more challenging with the “new brain”.  If you haven’t learned the new habits and don’t understand what all of the problems are, the world is a bit upside down.  That’s where we as therapists come into the picture.  Unfortunately, many insurance companies don’t recognize cognitive rehabilitation as anything other than “experimental and investigational” and will therefore deny payment for the treatment.  So how do you give the person the treatment that they need when the funds aren’t there to do so?

The question I often hear is, “Patient X got therapy services in the hospital/acute rehab/home health.  Why won’t the same insurance company pay for it in outpatient?”  There could be several reasons, starting with the difference in the nature of the treatment at the various stages of rehabilitation.  In the acute phase, depending on how severe the injuries were to begin with, the start of treatment might have primarily focused at addressing dysphagia or establishing basic communication.  As treatment progresses the immediate life safety issues become less of a focus of treatment and basic to intermediate cognitive communication skills are addressed.  By the time the client is discharged to home or a supervised living setting in the community, the needs of the person have shifted to more complex cognitive communication needs, such as higher level attention and concentration, memory, executive function skills or pragmatics.  If the insurer is a commercial insurance who sees cognitive rehabilitation as experimental, these needs are not something they consider as essential to basic life safety or functioning in the home.  They are not concerned about whether this person can return to work or resume their full roles within the family.  Chances are also good that this person will exhaust their lifetime benefit, or be off of work long enough to exhaust their COBRA rights.  Once those have occurred, the insurer is no longer responsible and the state may have to take over with Medicaid funds or another insurer will be sought by the family.  Working through the Social Security system is no guarantee, and one has to be disabled for a year before they can even become eligible for consideration.

So back to case, what are the options for funding treatment?  If you are a contracted provider with the insurer, you have agreed to accept assignment and to inform the patient and their family of services that you expect to be “non-covered”.  As with Medicare, you must have the equivalent of an “Advanced Beneficiary Notice” signed by the patient or their representative before you deliver services in order to get paid for them.  Essentially this document makes the patient financially responsible for the non-covered services and you may bill them at your posted rate.  Without this document, you lose all rights to bill them for anything the insurance company doesn’t cover.  In other words, funding for treatment becomes a combination of private pay and insurance pay. 

The next question I hear at this point in a conversation is, “But we use the same codes for treatment no matter what the site of service is.  Why is it denied at the outpatient level and not in inpatient?”  The answer again has to do with the nature of the treatment being provided.  In the outpatient setting, you are also more likely to use the 97532 CPT code for “Cognitive retraining”, since it describes more accurately what you are doing than 92507 for “Speech and language treatment”, although either one can be used, but not at the same time.  Also, beginning in 2008, there is a new code being added to the CPT list specifically for cognitive performance testing (96125).  We should be using the codes which best describe what service we are providing.  In doing so, we will almost always tip off the system regarding the nature of our treatment.  The bills you submit first go through computer edits and are paid or denied often without human eyes reviewing them.  It’s only when a claim is denied and the billing department contacts the insurer for review of the payment that a human eye looks at what’s been submitted.  This will usually trigger a request for notes to accompany a resubmit of the claim.  If it wasn’t clear before that you were providing cognitive rehabilitation, it will be now.  Should you do something in your notes to make it a little more difficult to see what you’re doing?  The simple answer is “No.”  I would suggest, however, that as you write your notes the first time, that you emphasize the language based processes that you are addressing.  You often can’t avoid the word “cognition”, but you can emphasize the executive function skills, the auditory processing and retention, and the verbal expressive clarity or reduction of circumlocutive language patterns that you may be addressing.

If the family does not have the ability to pay privately, there are a few other options.  I read recently of a suggestion by an attorney to use a pending lawsuit settlement as an incentive to the insurer to fund treatment.  In this case, money that the insurer expends on behalf of the patient is recouped by the insurer once the case is settled.  Remaining on the subject of legal action, the patient has the right to appeal their denied claims.  If they have exhausted their internal appeal rights and still find themselves with denied claims, they then have the right to request an external review.  There are several attorney members of the Brain Injury Association of Oregon who would be able to help them with these processes.  The Oregon Advocacy Center, a nonprofit organization providing legal advocacy services to persons with disabilities, is actively seeking families whose claims have been denied in order to file a class action suit.  External appeals have worked in other states to overturn the ruling of the insurer and have resulted in policy change. 

Other options for funding outside of the private pay and legal arena are few and far between.  Some funding can be sought through Crime Victims Assistance if they were a victim of a crime.  Other funding can be sought through the Oregon Vocational Rehabilitation Division.  Some people have approached their churches or other charitable organizations for assistance.  Some people have tapped into their savings plans, such as their 401K, IRAs or other retirement savings, college savings they may have been putting aside for their children, or taken a second mortgage on their homes.  These all come with a financial penalty, of course, but when the alternative is no treatment, the penalty often becomes worth sustaining.  Both Portland State University and the University of Oregon have clinic programs that are at reduced fees compared to private or hospital based outpatient clinics.  Most hospitals have sliding scale fees that can be applied once the person demonstrates financial need. 

While the obstacles remain many and frustrating for cognitive rehabilitation funding, they are not impossible.  If you are in a hospital based outpatient clinic, ask for assistance from the Social Service department.  If you are in a private practice, talk to your Billers; they are often a wealth of information when it comes to how to get paid for what you do.  Finally, contact the Brain Injury Association of Oregon at www.biaoregon.org or the Oregon Brain Injury Resource Network at www.tr.wou.edu/tbi   Both of these organizations are a wealth of resources and can help you with local professionals who may be of further assistance.

Kathy de Domingo, MS, CCC-SLP