Rehab - Out of Network (Insurance - USA)

Thank you to everyone in this community. I've found previous posts helpful as I've had a loved one (LO) experience a critical illness recently. I won't go into the complete history of the case, but I want to share a bit of my current situation to see if anyone can give some advice.

Basically a LO was in the ICU for about 7 weeks. During that time they were sedated for 5 weeks, trached & PEG'd. (Also suffered a collapsed lung and a UTI, but those issues have resolved.)

I now have the challenge of finding a rehab facility. My ideal choice is out of my LO's insurance network. I know that the insurance can negotiate a one time contract with this rehab facility, but they want my LO to go a place in their network. They even said via the social worker that they would "consider" negotiating a one time contract only if all of the in-network places rejected my LO. Some rehab facilities in their network have accepted my LO, but these facilities don't have good reputations (online) & they aren't easily accessible for people in my LO's support network.

Does anyone have any ideas as to how I can persuade the insurance company to negotiate a one time contract with the rehab that is my leading choice. Also I want to note that my leading choice has said that they can handle the medical complexity of my LO, while some of the better reviewed places in my LO's insurance network denied my LO due to complexity of care (mainly suctioning & oxygen needs).

Thanks in advance.

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  • *UPDATE*

    My LO has been approved to go to my ideal rehab facility of choice. The facility is out of their insurance's network, but the insurance company and the rehab facility were able to make a one time contract.

    I can't say for certain what made this work, but there are a few things that come to mind: 1) a lot of places in the network didn't accept my LO due to medical complexity, 2) I had called the insurance rep (even though I wasn't supposed to). The rep told me that I wasn't supposed to have their number and hung up on me, 3) I tried to give the social worker the argument as to why this location was ideal so that they could pass that they could better lobby the insurance company: things like medical complexity and accessibility for people in my LO's support network, 4) I made it clear that I was willing to appeal a denial, 5) My LO has been hospitalized for weeks so maybe (?) the insurance company was more willing to get her to the next level of care so that it reduced their financial burden (I really don't know though), 6) I made it clear that my ideal location was a viable option and that it was more a matter of the insurance company's willingness to negotiate a one time contract.

    Maybe I got lucky. Hopefully this is the best decision and outcome for my LO. They'll definitely have more visits from friends and family thanks to the facility's accessibility, and based upon my visit it seems like the facility is equipped for my LO's needs.

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