Advice PLEAAAASEE

[chenoaspirit, ASN, RN]

I have a patient diagnosed with glioblastoma. She has private insurance. Insur approved 27 visits for SN, 27 for PT and 27 for OT. She is homebound, she cant walk or use the left side of her body. Our PT are NOT aggressive AT ALL, they hardly do anything in the home. This patient is wanting to be involved in a clinical trial, one of the requirements is to be mobile...so she is going to go to OP therapy once per week (they have equipment and are working really hard with her to try go get her more mobile so she can get into this clinical trial). Her husband is having to take off work this one day to take her. My problem is, Im worried that her insurance will now consider her no longer homebound, but she really is. I go only when necessary so I can conserve the visits for necessity. She has a PCA pump, decubitus on her coccyx, has multiple med changes that require ALOT of teaching. Our insurance dept was supposed to let me know today, but I havent heard anything from them. Im soooo worried about this patient. She has SMALL kids and she cries all the time. She is truely depressed (understandable). She is not wanting hospice because she feels like that is "giving up", but she is palliative. If insurance denies anymore SN visits, Im going to call them personally and discuss this with them. Its a REAL hardship for her to get out of the house. She cant stand or walk without total assist. What can I say/do that will maybe make the insurance reconsider? They havent denied yet, but I have a feeling that they will. I know that with Medicare, you cant continue if they receive any outpatient tx's, but she has private insurance. Anyone else ever have a situation like this? There is such a fine line with being homebound and patients like this fall into the cracks.

[berube]

I have a patient diagnosed with glioblastoma. She has private insurance. Insur approved 27 visits for SN, 27 for PT and 27 for OT. She is homebound, she cant walk or use the left side of her body. Our PT are NOT aggressive AT ALL, they hardly do anything in the home. This patient is wanting to be involved in a clinical trial, one of the requirements is to be mobile...so she is going to go to OP therapy once per week (they have equipment and are working really hard with her to try go get her more mobile so she can get into this clinical trial). Her husband is having to take off work this one day to take her. My problem is, Im worried that her insurance will now consider her no longer homebound, but she really is. I go only when necessary so I can conserve the visits for necessity. She has a PCA pump, decubitus on her coccyx, has multiple med changes that require ALOT of teaching. Our insurance dept was supposed to let me know today, but I havent heard anything from them. Im soooo worried about this patient. She has SMALL kids and she cries all the time. She is truely depressed (understandable). She is not wanting hospice because she feels like that is "giving up", but she is palliative. If insurance denies anymore SN visits, Im going to call them personally and discuss this with them. Its a REAL hardship for her to get out of the house. She cant stand or walk without total assist. What can I say/do that will maybe make the insurance reconsider? They havent denied yet, but I have a feeling that they will. I know that with Medicare, you cant continue if they receive any outpatient tx's, but she has private insurance. Anyone else ever have a situation like this? There is such a fine line with being homebound and patients like this fall into the cracks.

first let me say, i feel for your patient....i haven't had a patient like you are describing but did have a private insurance patient that went out patient for PT and ST (parkinsons) and they allowed me to stay in for nursing,,,,i surely don't see how they can deny SN visits esp with a PCA pump,,,i so hope she gets what she needs.

[caliotter3]

Have you discussed this with the Director of Patient Care Services? They are supposed to be the people in the agency who have dealt with these issues the most in the past, and s/he should be involved with the patient's case to the point where they would be communicating with the insurance company if need be. I would seek guidance from her/him.

[aubreysmommy]

She will more than likely continue to be considered homebound. There are many many homebound pts that have routine outpt visits, so I don't see this being a problem. My grandmother just lost her battle with this very nasty disease and she had regular outpr visits and was still considered homebound. Its a really sad disease.

[gr8rnpjt, RN]

I've worked for insurance companies for the last 20 years, and the "homebound" criteria are not so cut and dried. There are patients who receive services in the home while they go out to dialysis 3 times a week, go to weekly Doctor visits, and even go to visit relatives for the day and are still considered homebound. I wouldn't stress about it.