When John Karadell suffered a stroke, his medical team emphasized the urgency of starting intensive rehabilitation immediately.
“Almost immediately they started telling me that the No. 1 most important thing now is to as quickly as possible get me into what they call acute rehab,” said Karadell, 58, of Howell, Michigan. “They used words like, ‘This is crucial. This is essential to your recovery.’”
Despite medical recommendations, Karadell remained in a hospital bed for 11 days without news of a transfer. He later discovered that his insurer, Aetna, had denied coverage for acute post-stroke rehabilitation.
What followed was weeks of bureaucratic delays, phone calls, and miscommunications between University Hospital in Ann Arbor and Aetna, according to hospital records, NBC News reporting, and statements from both organizations.
After more than a month, Karadell opted for a less intensive rehabilitation program, contrary to the plan recommended by his care team.
“I’m left with what I believe is permanent damage,” Karadell said. “And I’m left to wonder: Could it have been different if they would have approved what they should have done?”
An Aetna spokesperson described the situation as “complex” and noted that the insurer’s ability to process claims depends on the “timeliness and comprehensiveness” of information from providers. The spokesperson emphasized that most claims are processed smoothly and that Aetna partners with healthcare providers to ensure members receive appropriate care.
Karadell’s experience is not uncommon. A survey of over 1,300 insured adults found that 36% had experienced at least one claim denial, with nearly 60% of those facing repeated denials. Half of the patients who were denied care postponed treatment, according to Miranda Yaver, an assistant professor at the University of Pittsburgh.
“This is a form of rationing care by inconvenience,” Yaver said. “Health insurers make the process difficult through repeated denials or complex appeals, counting on patients and doctors to give up.”
Stroke specialists stress that early rehabilitation is critical. Acute post-stroke rehabilitation is intended for patients who face significant challenges with daily activities but are medically stable. Delays can worsen long-term outcomes, including permanent disability.
Hospital notes show that Karadell struggled with dressing, bathing, and eating independently. Despite progress in hospital therapy, doctors recommended a more intensive rehabilitation program. Dr. Nneka Ifejika, chief scientific officer at Ochsner Health System, said starting rehab within two to three days of a stroke is essential to maximize recovery.
University Hospital submitted a prior authorization request on June 12, but Aetna denied it on June 17, citing insufficient clinical documentation. Despite appeals, delays continued, and Karadell remained hospitalized with little progress toward transfer. By July, after nearly a month, Karadell chose a less intensive, subacute rehabilitation program at a nearby facility.
Subacute care, often provided in nursing homes or assisted living facilities, is easier to approve but carries a higher risk of hospital readmission and generally provides less therapy than acute rehab. Karadell’s wife said he received limited physical therapy and suffered a fall during the stay.
Karadell now faces ongoing physical challenges, including numbness, reduced mobility, and difficulty with basic tasks. He also carries a pending hospital bill of over $150,000, with Aetna covering roughly $37,000 and the remainder written off by the hospital.
Healthcare experts say reform is needed. Prior authorization processes, intended to manage costs, can delay critical care, destabilize patients’ health, and contribute to physician burnout. Past promises by insurers to streamline approvals have largely failed to produce lasting change.
“I always have to watch my step,” Karadell said. “When I leave the house… I’m scared of falling. This experience changed my life forever.”
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