Why A Michigan Man Waited Over A Month In The Hospital For Stroke Rehab

When John Karadell was admitted to nan infirmary after a stroke, his doctors quickly pushed for him to statesman an intensive shape of rehabilitation — nan sooner nan better.

“Almost instantly they started telling maine that nan No. 1 astir important point now is to arsenic quickly arsenic imaginable get maine into what they telephone acute rehab,” said Karadell, 58, of Howell, Michigan. “They utilized words like, ‘This is crucial. This is basal to your recovery.’”

But aft 11 days successful a infirmary furniture pinch nary connection connected erstwhile he’d beryllium transferred to nan facility, Karadell said he learned his wellness insurer, Aetna, had denied sum for what’s known arsenic acute post-stroke rehabilitation.

What followed was a weekslong back-and-forth betwixt Aetna and nan hospital, University Hospital successful Ann Arbor — including telephone calls, bureaucratic delays and miscommunication, according to a Michigan Medicine spokesperson, an Aetna spokesperson and infirmary lawsuit notes reviewed by NBC News.

More than a period aft Karadell’s stroke, he said he fundamentally gave up and near nan infirmary to spell to a less-intensive rehab program, a downgrade from what his attraction squad consistently recommended passim his infirmary stay.

“I’m near pinch what I judge is imperishable damage,” Karadell said. “And I’m near to wonder: Could it person been different if they would person approved what they should person done?”

John Karadell and his wife, Emily Steiner.Courtesy Emily Steiner

In a statement, an Aetna spokesperson said nan circumstances surrounding Karadell’s denied declare are “complex” and nan insurer’s expertise to process claims and appeals is “dependent connected nan timeliness and comprehensiveness of nan accusation we person from nan provider.”

“We understand nan vexation whenever location is simply a wellness attraction process that is analyzable aliases does not meet a member’s expectations,” nan spokesperson said. “Even though nan immense mostly of experiences are managed smoothly, our institution strives to partner pinch healthcare providers to make judge each personnel receives what’s expected each time.”

The spokesperson added, “as we are not successful nan infirmary pinch this patient, we expect our providers to partner pinch america and play an progressive domiciled successful conveying important objective accusation to america that we would not different have.”

Karadell’s experience, however, is acold from unique: A nationwide study of much than 1,300 insured adults recovered complete a 3rd — 36% — had had astatine slightest 1 declare denial, said Miranda Yaver, an adjunct professor successful nan section of wellness argumentation and guidance astatine nan University of Pittsburgh who conducted nan survey. Almost 60% of those patients, she said, went connected to person nan aforesaid declare denied aggregate times. Half of nan group who were denied ended up postponing their care.

If you are dealing pinch bills that look to beryllium retired of statement aliases a denial of coverage, attraction aliases repairs, whether for health, location aliases auto, please email america at Costofdenial@nbcuni.com.

What appears to person happened to Karadell tin beryllium champion described arsenic “rationing attraction by inconvenience,” said Yaver, who wasn’t progressive pinch Karadell’s case.

It’s a tactic, she believes, that wellness insurers usage to limit spending. By making nan process of getting sum difficult — either done paperwork, repeated denials aliases a analyzable entreaty process — they count connected doctors and patients giving up.

“It’s not that you’re ne'er going to get nan approval, but it ends up being this endurance title and administrative burden,” she said. “And it’s really overwhelming, particularly because erstwhile we’re navigating these things, it’s not connected our champion day, it’s connected our worst.”

‘Discharge has been delayed’

Some shape of rehab is recommended for each patients aft a stroke, according to nan American Stroke Association.

The programme recommended for Karadell — known arsenic acute post-stroke rehabilitation — is typically for patients who still person important difficulties, specified arsenic problem walking, feeding themselves aliases bathing but are medically unchangeable capable to tolerate therapy, said Dr. Nneka Ifejika, main technological serviceman astatine Ochsner Health System successful New Orleans and an ASA nationalist unpaid expert. Ifejika was not progressive successful Karadell’s care.

In a infirmary statement dated June 8, 2024, 2 days aft he was admitted, Karadell was described arsenic still having important trouble getting dressed, bathing, brushing his teeth and utilizing nan bath connected his own. He besides required immoderate thief eating meals. He had dizziness and aggravated symptom successful his neck. His wife, Emily Steiner, besides said he had imagination and reside problems. The statement said he was doing good pinch nan therapy he was getting astatine nan infirmary but recommended a much intensive program.

“Progressing good successful therapy, will greatly use from multidisciplinary rehab astatine IPR [inpatient post-acute rehabilitation] to facilitate maximal independency successful ADLs [activities of regular living] and functional mobility anterior to return home,” nan statement said.

Ifejika said that it’s critically important for stroke patients to commencement rehab arsenic early arsenic imaginable because delays tin lead to worse wellness outcomes, including semipermanent disability.

The longer a changeable diligent is bedridden, nan much their beingness expertise and mobility decline, she said. Extensive stays successful nan infirmary tin besides lead to accrued consequence of falls aliases getting an infection, she said. (In Karadell’s case, his woman said, it besides took a intelligence toll, arsenic he had problem sleeping owed to sound and patients sharing nan room.)

Ifejika said she typically starts patients successful rehab wrong 2 to 3 days of a stroke. “They spell straight from nan infirmary to nan rehab facility, whether it beryllium a freestanding rehab installation aliases a hospital-based rehab facility,” she said.

University Hospital successful Ann Arbor, Michigan.NBC News

The infirmary spokesperson said nan hospital’s admissions coordination submitted a anterior authorization petition for Karadell’s intensive rehab connected June 12.

On June 17, Aetna denied nan coverage, saying that objective archiving hadn’t been submitted, nan infirmary spokesperson said. The spokesperson added that nan insurer did not connection an opportunity for a infirmary expert to speak to a expert from nan security institution astir nan request, a process known arsenic a peer-to-peer review. An Aetna spokesperson said it would person provided a peer-to-peer reappraisal if nan infirmary had requested it.

The infirmary submitted an expedited entreaty that day, nan infirmary spokesperson and Steiner said. An Aetna spokesperson said nan hospital’s entreaty was not submitted arsenic “expedited.”

That aforesaid day, a infirmary statement said that Karadell was “significantly beneath baseline of function,” adding: “Recommend IPR to advancement independency successful ADLs.” In a 2nd statement besides dated June 17, a expert wrote: “Today, discussed pinch diligent will proceed to activity connected IPR admission. He states he is disappointment pinch really agelong it has taken but hoping to statesman therapies soon.”

One week later, however, Karadell was still successful nan hospital. “Discharge has been delayed by rejected security authorization contempt our beardown aesculapian proposal for discharge to IPR,” a expert wrote successful a June 24 note.

Two days later, connected June 26, a infirmary statement said: “He and woman proceed to sound their vexation regarding nan insurance-related delays.”

In nan days that followed, nan infirmary said Aetna denied nan support for a 2nd time.

Subacute care

On June 30, astir 30 days aft Karadell’s stroke, Aetna said it approved nan intensive rehab, but nan infirmary spokesperson said they didn’t person nan support until July 5, a Friday. That Monday, nan infirmary said it contacted Aetna to corroborate nan support but learned it had expired nan time before. At that point, Karadell gave up and opted to get little intensive rehab person to location — an action that his attraction squad had been considering arsenic a backup and had already been authorized. (Aetna said it had canceled nan intensive rehab support because of nan hospital’s petition to nonstop Karadell to a less-intensive program, arsenic nan 2 requests were mutually exclusive.)

Ifejika said that alleged subacute care, which is often provided astatine an extracurricular facility, specified arsenic a nursing location aliases assisted surviving facility, is easier to get security support for because it’s little expensive.

However, she added, studies show it comes pinch a higher consequence of infirmary readmission compared to acute rehab.

“Sending them to a skilled nursing installation is really doing them a disservice,” she said.

Steiner said the assisted surviving installation Karadell went to only had a part-time beingness therapist, and he was doing little rehab than he had been doing astatine nan hospital.

Karadell successful nan hospital.Courtesy Emily Steiner

At 1 point, he said, he needed thief getting up to usage nan bath but couldn’t get assistance and ended up falling.

“That was rather frankly awful,” Steiner said. “None of this I knew astatine nan time, really really important of a quality it was going to be.”

Karadell near nan installation aft astir 2 weeks. Though he could person stayed longer, “I wanted to spell location truthful desperately,” he said.

Karadell was besides near pinch a measure for much than $150,000 marked “pending” successful his infirmary file, nan consequence of his extended stay. When NBC News precocious asked nan infirmary astir nan bill, a spokesperson said it had been going backmost and distant pinch Aetna complete really overmuch would beryllium covered. Aetna paid astir $37,000 and nan infirmary wrote disconnected nan rest.

Prior authorization

Health insurers person pledged to return steps to streamline nan often-criticized prior authorization process for approving claims.

In June, Health and Human Services Secretary Robert F. Kennedy Jr. said nan country’s largest wellness insurers had promised to take steps to betterment anterior authorization, including quicker approvals and reducing nan number of aesculapian services taxable to nan rule.

Health insurers person made akin commitments successful nan past, including successful 2018 and again successful 2023. Many grounded to instrumentality specified reforms.

Dr. Adam Gaffney, a captious attraction expert and adjunct professor astatine Harvard Medical School, said much basal reform, apt from Congress, will beryllium needed to reside nan wellness attraction barriers imposed by security companies.

Yaver, of nan University of Pittsburgh, said galore doctors — and patients — work together that betterment is needed.

In much than 100 interviews pinch doctors, Yaver said galore had stated that nan anterior authorization process had gotten much difficult complete nan years, not easier.

“On nan expert side, this requires a batch of clip and staffing,” she said. “Some of them property this to contributing to burnout.”

On nan diligent broadside it “destabilizes their wellness and economical lives,” she added.

Karadell — who says he still has numbness successful his legs, back, look and feet and struggles pinch elemental tasks, for illustration climbing stairs and reaching for nan distant — said nan acquisition “changed my life forever.”

“I ever person to watch my step,” he said. “When I time off nan location and I spell to nan shop aliases to spell get thing to eat, I person to watch nan crushed because I’m frightened of falling.”