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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #11  
Old 11-07-2005, 04:20 PM
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Puelette,
Thank you for your kind welcome. I have found the people here to be very welcoming and more than willing to help. Thank you for your offer to let me use parts of your letter!

Pat,
I have found that Medicare will pay for the surgery but the amount they are willing to reimburse is less than what the hospitals will accept, especially for the disc itself. This seems to be a big sticking point. Do you have any suggestions how to overcome or get around this? Any thoughts would be greatly appreciated.

Thanks!
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  #12  
Old 11-07-2005, 04:24 PM
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Paulette,
Sorry about spelling your name wrong! I can't seem to figure out how to fix it.
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  #13  
Old 11-07-2005, 04:52 PM
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Paulette,
I hope you don't mind another question?

Were the articles that you sent with your letter "4 published reports and articles from medical and scientific journals and literature..." provided by Dr. D. or did you find these on your own? I have articles that were provided to me by Depuy Spine. Can you share what articles you provided?
Thanks !
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  #14  
Old 11-07-2005, 10:49 PM
letteski letteski is offline
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Freshfig,

Yes these were 4 published reports and articles from medical and scientific journals and literature provided to me by Dr. D research department. 2 from Dr D, 1 from Dr Zigler and the other a 10 year old study all on the Prodisc. I can�t post them because they are on PFD but if you PM me your email I can email them to you.

No worries about the spelling I am know around here for my creative spelling. What are you doing on Sat? I will be in LA and we are having a gathering in Marina Del Ray for anyone from the forum that wants to connect with other spinies. You can read more here Hope you can make it.

One way to get around the cost of the disc is to get involved in a study the disc is paid for by the study. I would call Dr D�s and see if they have any study�s opening in the near future. The Prodisc vs ActivL sounds real interesting.
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Paulette
ProDisc L5-S1 W/Dr Delamarter Aug 23, 2005
L5-S1 DDD Diagnosis 12/04
T-12 Compression Fracture 10/04
C-7 Spines Process Fracture 5/99
http://prodisc2.blogspot.com/
You are my Rock God in you I can do anything
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  #15  
Old 11-08-2005, 05:10 AM
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Freshfig,

All I can say to your Medicare question is to keep asking questions and get the names of the people who answer them and try to record your phone calls with them to document their responses. You need to inform them that you are recording the call to keep it legal for your protection. If they won't agree to the recording then just try to document response in writing as they give it. You are now in a negotiation to force two entities to live up to their contractual agreement with you and each other. You are close to getting it done it is just a matter of the bottom line cost for everyone.

First find out if your Dr. and hospital has a contract with Medicare and accepts other Medicare patients. Some do, some don't. If they do have a contract with Medicare ask them why they won't accept Medicare's figures and then contact a Medicare lawyer as to your legal rights to force the hospital to live up to their contract with Medicare. I would guess that if they have a contract with Medicare then they have one with you by default.

If your Dr. and hospital don't have a contract with Medicare ask Medicare why the reimbursement is so low for this surgery? Ask them how they determine what their reimbursements rates will be for any surgery and where in your Medicare contract does it spell this out in writing. Ask them what hospital and qualified Dr. do they have available that will accept their figures to do this surgery. Try to back them into a corner where their answers will trip them up.

At the same time you are working on Medicare ask your Dr. and hospital how far a part the Medicare reimbursement rate is from what they will do it for. Ask them if you can make up the difference. Once you got the figure then ask them what kind of payment plan will they accept to help you out with this. If you can get the hospital and Dr. to agree to do it with out you paying all the difference up front then go for it and worry about how you will pay for it later. Unpaid medical bills will not impact your credit as other bad debts do, and as long as you can make some kind of regular payment to the hospital they will wait for it.

Your goal here is to get fixed so you can get back to living a normal and productive life. I must also say that only you and your Dr. know your medical situation. I assume that you both agree that ADR is the best course of action for getting you better. There are risks to this surgery and you have to be prepared to deal with a less them optimum outcome. Your pain and quality of life should be so bad that anything will be better then what you are living with today.

Good luck with it. You are close and persistence does pay off

Pat
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  #16  
Old 11-11-2005, 03:00 PM
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Paulette,
Thanks, I will PM you and give you my e-mail address. If you can send the articles that would be a great help!

Where can I find the address for the BBQ this Sat.? I would like to come but this past Wed. I had a shot in my butt and the woman hit my sciatic nerve, even though I warned her to keep away from that area. She assured me that she was aware of the pain, as she had been attacked by a dog and has herniated disks from that attack.

Needless to say the next day I was in excruciating pain from her hitting that nerve. This is the third time this has happened. No more shots in the butt!

If I can walk by tomorrow I would like to come. Can you e-mail the address with the articles?

Thank you so much for your help!
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  #17  
Old 11-11-2005, 06:49 PM
BRENDAWY BRENDAWY is offline
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Paulette, I am so happy for you. This instills hope in us all. That was a very clever way to go about your appeal. I will be using some of it for my next letter. I am still going to Germany, but would like my insurance to reimburse me. Congratulations! BrendaWY
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  #18  
Old 03-12-2007, 02:05 PM
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CindyLou CindyLou is offline
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I'm wondering, Paulette, or anyone out there, really. Could you email me those four published reports and articles from medical and scientific journals and literature deemed to be authoritative within the medical community? I would really appreciate it. I'd like to add that with my cover letter to my appeal with HealthPartners. Thank-you, thank-you Cindylou
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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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  #19  
Old 03-12-2007, 02:57 PM
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Harrison Harrison is offline
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CindyLou (and others),

If people want to help you by sending you the articles you requested, you need to have your email visible in your public profile:

GO > Personal Zone > Profile > Edit
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  #20  
Old 03-12-2007, 04:14 PM
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CindyLou CindyLou is offline
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Harrison,
I think my email is visible. Someone sent me a private email message yesterday, so should I assume I am all systems go? You can tell I am not that techy savy!
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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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