LINCOLN — Boston Bieler grimaced as he struggled to move one arm, then the other, on a recent afternoon. Each repetition was a victory.
Seven weeks earlier, the Beatrice man could barely move his right arm or shrug his shoulders.
A gunshot wound to his neck had left him unable to budge his left arm or sit upright for more than two hours at a time. He used a sip-and-puff system, relying on air pressure, to move his wheelchair. He had to have someone at his side everywhere he went.
Now, with effort, Bieler can lift, bend and straighten both arms. He can sit for several hours a day in the wheelchair, doing physical and other therapy. And, using a joystick, he can drive the chair by himself all over QLI’s Omaha campus.
He hopes eventually to regain enough functioning to hold his children, work a job and live independently.
“I have always been that person that, you’re not going to tell me I can’t,” Bieler said.
But he and his family now fear that he won’t have the chance to reach those goals.
A private company managing the care of Nebraska Medicaid patients has cut off funding for Bieler’s rehabilitation at QLI, a nursing facility specializing in brain and spinal cord injury rehabilitation.
Nebraska Total Care, operated by the St. Louis-based Centene Corp., denied authorization for continued services as of July 2. The company stuck by the denial after a “peer-to-peer” review, in which a QLI neuropsychologist talked about the case with a Nebraska Total Care professional.
Heidi Woodard, a Nebraska Total Care spokeswoman, said the company could not comment on Bieler’s case because of privacy laws. But she offered a general explanation for the company’s decision.
“Managed health care, like all quality focused health care, is about providing the right care for an individual patient at the right time,” she said. “Based on a patient’s response to treatment, a decision may be made that services will be more appropriately rendered in a different setting than previously received.”
The family’s understanding is that Bieler was not making as much progress as the company’s guidelines stipulate.
Jeff Snell, the QLI neuropsychologist, said Bieler may appear to be making slow progress when managed care reviewers look at the time elapsed from his injury. But he argued that Bieler still needs — and can benefit from — the intensive rehabilitation services offered by QLI.
He was shot March 11, while celebrating his 23rd birthday. Nathan A. King of Beatrice has been charged with attempted murder, second-degree assault, terroristic threats and use of a weapon to commit a felony in connection with the shooting.
Bieler applied for Medicaid while at a Lincoln hospital. He was too new at his job at a car dealership to have health insurance.
He moved from the hospital to QLI on April 19. But he arrived with an open pressure sore and wasn’t able to start active rehabilitation for more than a month while it healed.
“We feel that, given his history, his injury, he is showing progress,” Snell said. “We don’t feel the maximum benefit has occurred.”
Bieler, his family and QLI are fighting for his care to continue. The next step is a formal appeal to Nebraska Total Care. If that fails, they could ask for a hearing from state Medicaid officials.
He isn’t the only QLI patient battling for care.
Snell said the facility has been encountering more authorization problems in the past couple of years, the same time period in which Nebraska revamped its Medicaid system.
Under the new system, called Heritage Health, the state contracts with three private companies to manage and pay for the bulk of Medicaid services. The companies — United HealthCare Community Plan, Nebraska Total Care and WellCare of Nebraska — administer about $1.2 billion worth of physical health, behavioral health and pharmacy services for almost all Medicaid recipients.
The companies have struggled with unpaid claims and balky authorization processes since the system’s 2017 launch, which has frustrated health care providers and at times delayed care for patients.
Bieler is among nine QLI patients whose cases are on appeal after Heritage Health companies refused to authorize rehabilitation services in a peer-to-peer review, Snell said. The patients continue to get care, but the facility does not get paid during the appeal. It’s not clear what would happen if all of Bieler’s appeals are denied.
State Medicaid officials declined to comment on Bieler’s case, citing health care privacy laws.
A spokeswoman offered a general statement: “Nebraska Medicaid cares deeply for the clients that are served by Heritage Health. … We stand ready to help this individual and all others through the appeals process.”
Deputy Medicaid Director Thomas “Rocky” Thompson offered sympathy in a letter sent on behalf of Gov. Pete Ricketts. The letter was sent to Penny Bieler, Boston’s stepmother, in response to her plea for continued rehabilitation services.
“I cannot imagine what your family has gone through over the past several months,” Thompson said. “I am glad he has seen improvement during his time at QLI.”
The letter recommended continuing through the Heritage Health appeals process.
In the meantime, Bieler keeps working to retrain muscles and nerves, heal his body and learn how to cope with his new situation.
“This is my life now, and I’m not going to sit there and dwell,” he said. “I’m going to make the best of it.”