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Old 04-06-2007, 11:16 AM
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CindyLou CindyLou is offline
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Join Date: Mar 2007
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So, here's the "official" scoop on my healthcare provider's decision, along with my husband's boss' input: trust me, it's convoluted, so bear with me. HealthPartners (HP from here on out) has "officially" turned down my second appeal, w/ exception being they will pay for the fusion part (this is if Dr. B. discovers he has to fuse my L6-S1, partially sacralized segment during surgery). Dr. B's office would have to break out costs associated with it, and HP stated by agreeing to pay fusion part (if needed) they will pick up costs of my hospital stay, the fusion, attending physicians, pt, any anesthesia, recovery in hospital, etc. And all we would have to pay would be for the ADR's themselves (what does a prodisc run? Anybody know? In Germany, not states.)and Dr. B's time on their implantation. (so of course, I'm thinking, fuse the son of a bitch)

Secondly, and I still can't wrap my head around this logic, but they decided (HP, the boss, and HR)that were the boss to decide to "over rule" HP's decision for denial, and make an exception, then this reimbursement of the procedure would be subject to IRS taxing and would have to be declared as income. (???) Is that a true statement, anyone? And if HP were to reimburse us it would establish a precedent and the boss does not want to set a precedent for other "unusual or extraordinary claims." that's a quote.

And finally, because the boss feels so bad about this (yeah, I can tell, the tears are running down his face already) and does not want us to have to bear this completely by ourselves, (even tho he explicitly told Rick the other day, he could pick up the phone and just tell HP to cover this for Cindy,if he wanted to, which was a "tease" to me) he has offered the following: 1. Pursue the MN Dept of Health option. If they direct HP to pay, it would be done on a non-taxable basis. (I told my husband I have run out of steam, and if he wants to pursue that avenue, go for it) 2. our medical expenses will be tax deductible for year 2007 (duh, not stupid Larry) and gov't will reduce our tax burden by 35-40% for our out of pocket. 3. lastly, (finally a bone tossed our way) the company will reimburse us for 50% of the costs that we have for out of pocket, meaning whatever the total bill is minus what HP chips in for the fusion (if performed) , the company will pay us a check , which still means it will be taxable income.

Whew. Better than a poke in the eye as they say. By my husband's calculations, between the amount that the medical deduction should save us on taxes (about 35% of the amount we pay), plus the 50% that the company will reimburse us for, we should eventually come out with about 85% of our out of pocket costs recovered. (by next year, of course, this time)

I am no accountant, so all I can say is, "I guess so." All in all, we are talking about not getting reimbursed for the tax deductible part until almost a year from now, if my calculations are right.

So you guys tell me.....a win or a lose? My husband thinks it's not a bad deal. I think it sucks, because I presented such strong material in favor of my adr procedure and adr in general, for you guys as well, who are fighting the fight too. The statistics I gathered were there. I honestly don't know, how in good conscience, they could turn it down as an "unusual or extraordinary claim." Where is the burden of proof there? Sorry this is so long. I cried and cried and cried some more yesterday. And how did I find out my disapproval? Through HealthPartners? No. An email from my husband!
They can all go to hell as far as I'm concerned. (sorry to whomever that might offend) I have it off my chest, and now I have to think good thoughts, feel at peace, all that good karma, because I leave in one week for my surgery. So, I ask you guys once again, what do you think, a win or a loss? (to me, big picture, it's still a loss, anyway you cut the pie)
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CindyLou
bicycle accident 6/19/01
2 compression fractures, T12, L1;
vertibroplasty @ above levels, 9/15/01
4/06 hip labral tear repair
4/07 Lumbar ProDisc replacement by Dr. B., 3 levels; L3-6
7/2/08 ALIF of L6-S1
7/30/08 Removed bone cement.
8/7/08 Diagnosed with pulmonary embolism, double pneumonia, collapsed left lung, pleurisy, pleural effusion.
3/10/09 right SI Joint Fusion; seeing light at end of tunnel, for first time in 8 years!!
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