Adults with Brain Injury Speak out in McMaster Study
Fair treatment matters in auto accident recovery. Brain Injury survivors have been telling us anecdotally for years, how barrier-free access to care and services, is essential to recovery.
We have seen firsthand, that delays and denials can have a detrimental impact on rehabilitation after serious neurological injury.
Some important survivor stories can be found here.
The goal in any program is to capitalize on a vital treatment window, when we can maximize the brain's natural neuroplasticity to maximize recovery. But what happens when those treatment resources are dependent on a complex regulatory third-party system?
What can happen when approvals and/or denials of resources can fundamentally change the course of recovery?
A recent study provides us some of those answers...
In July 2020, McMaster University graduate students presented a report in partnership with the Acquired Brain Injury Survivor Solutions group (ABISS), focusing on lived experience with the auto insurance system after traumatic brain injury (TBI).
This research was a collaboration between students at McMaster University (Laura Brooks, Yvette Hou, Daniella Reid, Aileen Zhou), members of Acquired Brain Injury Survivor Solutions (ABISS) and research supervisors Sheila MacDonald SLP and Dr. Lynn Turkstra.
What is ABISS?
According to their website ABISS began as a social group for individuals living with Brain Injury, that has evolved into an advocacy role, to improve the lives of people living with traumatic brain injury (TBI), especially those interacting with the auto insurance system.
ABISS states that their mission is "to be another resource for those living with TBI's". They hope to be a place to find resources that will benefit individuals on their rehabilitation journey.
Fair Access to Rehabilitation Coverage for Adults with Brain Injury
The ABISS group initiated this research project after recognizing that they shared similar negative experiences dealing with their insurance companies after their accident.
The goal of the survey and study was to gain an understanding of the experiences of other TBI survivors in obtaining insurance funds for medical rehabilitation and replacement income.
Key Takeaways
The full report that can be found here.
Additionally the study authors have also provided a helpful infographic summary, capturing the main results.
In the study, we see that 41% of TBI clients did not get the treatment resources they needed and faced financial barriers to connecting with services.
Only 7% were completely satisfied with how their claims were handled.
In the two-page infographic from the study, we see a powerful word cloud. This is an amalgamation of common words and phrases that came up repeatedly in their client feedback survey.
"Denial...Liar...Stress...Unsupported...Nightmare Assessments"
Clearly this is a broken process that is hurting vulnerable ABI clients. They need our help to make systemic changes.
1. How Providers Help Facilitate Claims Approval Process
We'd like to further highlight a few points from a service provider perspective. Our teams at Key Metrix and Key Rehab Services hope to better understand client's in need, and support fair access to treatment with data-driven solutions.
What do we mean by advocacy and how does this differ from the role of the Personal Injury Lawyer? Our team prides ourselves in being SABs informed and aware of important LAT decisions that impact client care.
We acknowledge that clients can face barriers to care if their claims are denied. While it is the insurer's right to request an Insurer Examination (IE) or deny care, the implications for client care can be detrimental to recovery.
From claim denial, to IE to LAT meeting, the length of time the client can go with out a needed care or service can be 12-18 months. The ideal path is to reduce the chances of denial in the first place.
2. Provider, Know Thy SABS
It is imperative that treatment providers understand the Statutory Benefits Schedule (SABS), so that submissions can be made in accordance with those rules. It's important to provide the insurer with all relevant information to facilitate an approval.
This can be done with a simple phone call to the insurer adjuster when a new OCF-18 is submitted, even an email or fax explaining your rationale for a funding request, can go a long way.
What if the insurer isn't following up on denied plans?
We know that a skilled and experienced Personal Injury Lawyer is essential to help with these issues. Additionally, as a treatment provider, you can request a copy of the Explanation of Benefits, ask for the date of the scheduled IE and send supporting documents yourself to the IE assessor.
Once an IE is scheduled, you can request time for a phone consult with the assessor. Sometimes these requests are denied, but not always. The knowledge you have of your client from your depth of experience with the file, can be of great value in these situations.
While providers often have many responsibilities, it's important for us to keep in mind that our expertise with the SABS and helping clients navigate the claims process can go a long way to helping a client's recovery.
3. Clearly Communicate How Services are Reasonable and Necessary
It's important for services providers and clients to understand the difference between "it would be nice to have" and "reasonable and necessary". The SABS language on a treatment plan clearly states that this is threshold for services being approved.
Taking into account the client's injury diagnosis, providers need to explain clearly how the treatment recommended is essential and needed for recovery. Submitting a stack of OCF-18's and seeing what sticks, isn't doing our clients any favors.
We know that clearly communicating the goals for goods and services recommended is time-consuming, but for the client, getting that approval has important treatment value.
Fair adjudication of claims for benefits can often depend on the reporting, and communication the adjuster receives from the team.
As seen in the McMaster/ABISS study, there is a significant treatment value to ABI clients to have their program run smoothly, and if possible, avoid stressful IE's and treatment denials.
Next Steps
As issues of stressful insurer examinations, invasive surveillance and treatment denials continue to impact the ABI community, this will be a three-part series discussing the ABISS McMaster Study and how we can help.
Subscribe to our blog to get notified for next week's article where we will feature an in-depth interview with Sheila MacDonald, Speech and Language Pathologist and study facilitator. We explore the work of ABISS, the study's findings and next steps for the insurance industry.
Tamara Forbes is an experienced Case Manager and Instructor in Brain Injury Rehabilitation. She is a workshop facilitator in the McMaster University/HNHB Network ABI Training course and active member of the rehab community. Tamara is the Director of Client Services at Key Metrix and Key Rehab Services Inc. She is passionate about connecting our customers to solutions and resources.