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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 04-06-2007, 12:07 PM
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Terry Terry is offline
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CindyLou:

I am also sorry about the outcome. I understand the pain you must be in but I encourage you to not give up on yourself. I was forced to deal with my medical condition by my employer placing me on medical leave. I am the executive director but I answer to a board of directors. I had to make the decision and pay out of pocket with no guarantee of my lawsuit or insurance settlement.

Ultimately I had to make the decision that I thought was best for me; i.e., No Fusion Period! It cost about 64,000 and had to be paid up front. I do not regret the decision today as I stand upright and am in significantly less pain than pre-surgery.

"Illegitimi non Carborundum" - Don't Let The Bastards Grind You Down.

Do what is best for yourself and the rest will follow. You have one spine = one life. You may sacrifice now and look at it a couple of years from now and realize that ultimately the quality of your life is all that matters and there are no guarantees.

Good-Luck with a very difficult decision and believe that many are here to support you in the process.

Go with God Cindy.

Terry Newton
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1980 ruptured L4-L5
1988 ruptured SI-L5
1990 ruptured C5-C6
1994 ruptured C6-C7
1995 Hemi-Laminectomy C5-C6, C6-C7 Mayo Clinic
Bicycle Accident 2004
MRI, EMG, Facet Injections, Epidural Blocks, Lumbar Discogram.
Stenum Hospital Surgery November 4, 2006
Prestige Disc C5-C6, C6-C7
Maverick Disc S1-L5, L4-L5
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  #12  
Old 04-06-2007, 04:13 PM
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CindyLou CindyLou is offline
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Chuck, Kevin, and Terry.....thanks for the comments, support, etc. I had to already wire the full amount 3 weeks ago. Didn't you guys have to do that? At least at Pro-Spine, that's how Dr. B does it. I have made my decision to go ahead and have the surgery, obviously. I cannot allow anyone else to decide my fate, but I have to admit, for a few crazy, delirious, rage-filled minutes last night, after getting the news (still haven't heard from them directly..meaning HealthPartners) I was more than tempted to cancel my surgery, get a refund, be in more misery, get on stronger pain meds so I could sue the company for denying the surgery and contributing to an addiction to narcotics....and of course, it was all just being stupid, idiotic, my way of coping and how could I stick it to HealthPartners and the employer. I've had time to sleep on it, work thru some of my disappointment, and obviously get a clear head. (now I know for sure, after sleeping on it, it's a good plan! Ha! Just kidding!) I'm not a bitter or revengeful person by nature. It's just so wrong and unfair. I'm sure none of us like being unheard. In all my wildest dreams, I never could have thought this one up...that I would need a back surgery in America, sanctioned by my back surgeon and deemed medically necessary, only to have this same country deny me coverage! I feel like I'm living in some 3rd world country! Enough ranting and raving. I leave in a week. I refuse to utilize it starting another final appeal with the Minnesota Dept of Health, when I need to be just packing, reflecting, being positive and thankful for what's in front of me. Boy, thanks for all the support. I do appreciate it.
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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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  #13  
Old 04-07-2007, 04:13 AM
Judy Judy is offline
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Cindy if I understood correctly they will pay for the fusion correct and all associated costs. If you were to get a fusion at one level (hear me out)
they will pay:

all Hospital costs
all surgery costs asssociated with this correct?

That to me means you pay for the ADR only, if so you pay say $4000 each then the employer will reimburse you 50% of that cost so say you have 2 and it is $8000 then besides travel expense you are down to $4000, sound much better than most people have gotten?
Few insurance companies are paying, I realize it is still alot of money but I think you must have done a great job explaining ADR and what the benefits would mean or they would have just denied you.
I got Cigna to pay for my fusion part and had Dr. B office itemize the fusion hardware from the disc hardware on one invoice, the second invoice was for the hospital bill and last was for the doctors. They then paid for everything but the disc and after about 6 months after payment they are now claiming they over paid. We just told them they needed to provided documentation to us showing an overpayment and they never contacted us again, this was about a year ago and I don't know if there is a time limit on this and of course don't want to call them and ask the status so we have needed to hold onto $10K in the bank in case they change their minds.
Did I misunderstand what they offered you?
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Surgery Vienna by Dr. Bertagnoli Oct. 16, 2004
ADR L3/4
Fusion L4/5
ADR L5/S1
Diagnosed with Arachnoiditis 11/06
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  #14  
Old 04-07-2007, 08:38 AM
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CindyLou CindyLou is offline
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Judy, as far as my understanding of the conditions for them paying, I think that is what they are saying. A few posts earlier, I think it was Kevin saying last August one lumbar prosthetic device was going for about $5800. By now, I'm going to guess $6,000, so x 3= 18,000 we have to pay. (which like you said, money is money,but in my book, $18,000 is still alot and we're not done calculating yet ). Then, the kicker, we also have to pay for Dr. B's incremental expense for the time it takes him to implant them. My guess is it's going to take a whole heck of alot more time to implant those (since I need 3 lumbar discs replaced) than to do one L6-S1 fusion. (if it is deemed necessary) But, let's play off the scenario that I do have the one fusion...and no additional costs (i've already prepaid Pro-Spine $50,000 for the down payment),so by my calculations $50,000-18,000=32,000 refund minus Dr. B's time, for installing 3 adr's = the million dollar question!...I have no idea. Let's throw out a crazy low number: $10,000 for his time. (this may be laughable) Then you take that to our equation table: $32,000-$10,00= $22,000 coming our way. Finally, if those are our out of pocket expenses and the co. pays half of $22,000+ 11,000=$33,000. Then we are finally only out $17,000 out of pocket.(50-18-10+11= 33) And what if his time is way more than $10,00? Of course this is not taking into account 3 week hotel stay, food, airfare, etc. You are right...it is better than nothing. I'm not denying that. I just really wanted a big win, a win that would help pave the way for all of us needing ADR. I had my sights high,no doubt, like everyone I'm sure; I really researched, and wrote a thesis on my insights and personal history, like everyone else I'm sure. Insurance is just dragging their feet! The statistics are there! They are just hiding behind experimental and investigative! The big question: how long can they hide?? That's it. That's my story and I'm sticking to it. Thanks for your input Judy. Totally changing the subject: is it possible to pull a loose top over my head after lumbar surgery, or should everything be front buttons and zippers?
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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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  #15  
Old 04-07-2007, 08:42 AM
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CindyLou CindyLou is offline
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Judy...p.s. possession is 9/10's of the law! Take the money and run! ha-ha. (if you haven't heard from them by now I doubt you will)
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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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  #16  
Old 04-08-2007, 03:17 AM
Judy Judy is offline
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Cindy I agree possession is 9/10's I just wish I knew if they are dropping it so then I could pay the balance on my home equity that I owe for surgery. There must be a law somewhere about this but I researched and could not find anything and I surely don't want to call them and ask.

Hoping you the best this week I am sure everything will work out for you.
Judy
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Surgery Vienna by Dr. Bertagnoli Oct. 16, 2004
ADR L3/4
Fusion L4/5
ADR L5/S1
Diagnosed with Arachnoiditis 11/06
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  #17  
Old 04-08-2007, 01:09 PM
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CindyLou CindyLou is offline
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Judy, yes, of course, you want to put it to bed. Surely, somebody out here in forum land is an attorney or knows someone who knows someone that is an attorney. Anyone? If Judy got her insurance reimbursement and over a year ago they contacted her saying they over paid her by, what was it, Judy, $10,000? and now she has not heard anything else from them in over a year's time, should she still be looking over her shoulder (legally) for them to confiscate their funds? Who has the answer??
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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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  #18  
Old 04-09-2007, 07:31 AM
Judy Judy is offline
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Thanks Cindy maybe someone knows. Like you said it is like we are always wondering if they will or can come after us. I was hoping there was a time frame where they cannot persue this. It is just strange that we have not heard from them in so many months.
Is $10,000 worth taking us to court, I don't know? It is Cigna Healthcare and I think they are the worst. We had to fight this for about 14 months to get payment and the only reason I think they did pay us is that I believe because I got the States Attorney their help I probably would have never seen any of it.

Oh well I guess I have to keep holding onto it. My husband claims we will persue this as long as they dragged their feet to pay us anything.
Cindy good luck this week I am sure everything will work out fine, worry about your surgery and try not worry about the cost, remember you only have one back and your health is more important than the money.

Time will tell I guess.

Judy
__________________
Surgery Vienna by Dr. Bertagnoli Oct. 16, 2004
ADR L3/4
Fusion L4/5
ADR L5/S1
Diagnosed with Arachnoiditis 11/06
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  #19  
Old 04-09-2007, 04:33 PM
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CindyLou CindyLou is offline
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Judy, thanks for the kind words and encouragement. Am getting a bit edgy, with surgery around the corner, but had the most amazing day today in spite of myself. I must have had at least three perfect strangers tell me they were going to pray for me and my surgery, while I was out and about w/ my college son home for Easter break. Perfect strangers. Amazing. And yes, we will get an answer for you on this insurance nonsense. Where abouts in Connecticut are you from? I ask because my husband is from Glastonbury. All his relatives still live there and in surrounding area. Anyway, I still have not received any official denial from HealthPartners! No letter, phone call. Just what my husband heard at work and emailed to me. How disappointly unprofessional is that?! I must take a deep breath and get over it.
Take care! Cindy
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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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  #20  
Old 04-09-2007, 04:38 PM
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CindyLou CindyLou is offline
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Posts: 627
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spelling correction...disappointingly. I should have been an editor! I'm a knucklehead for spelling and grammar!

Cindy
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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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