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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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Old 11-02-2010, 11:10 PM
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Tatonka_usn Tatonka_usn is offline
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Default New experience for me....

While I'm sure this is certainly NOT a new subject for the numerous folks among you who have opted to pay out of pocket for medical care (ie ADR), I had a bit of an annoying, insurance-related episode today that I felt the need to vent (bear with me).

As my back continues to deteriorate, I've now begun (again) to search out qualified surgeons in the area who might be able to weigh in with some opinions/options. Now that I'm finally/officially out of the military healthcare system (TRICARE), I have the "freedom" to search out Doctors of my choice under my Aetna PPO. This is a whole new world for me, after being told for nearly 14 years who to see, when to see them, and how much motrin to take for any/all ailments. The experience (so far) has been tinged with both excitment (if that's the right word) and a sense of being overwhelmed.

So, I did a bunch of research over the last couple days in order to find good surgeons (neuro or ortho) in the Northern Va/DC area, and here's my little experience...in a nutshell. Upon recommendation of a friend, I contacted the Virginia Spine Institute, in order to try to get in for an appointment with Dr. Thomas Schuler (Ortho-surgeon and consultant to the Washington Redskins & many other local area athletes). He's apparently one of the primo spine guys in the area, and I figured "what the heck". Went through a 30 minute intake interview with his "patient coordinator" on the phone, and it really sounded like this was the way to go for me. THEN, we get to the part about insurance coverage, to which I casually replied "AETNA PPO" (like, "I'm so cool!"). My jaw nearly dropped when the lady advises me that they don't take ANY insurance, but have an "insurance liaison" who will coordinate with my carrier to see what can be done. I think you could have heard a pin drop, as I was speechless. So, after spending GOBS of money on this wonderful plan, it's essentially useless, and I'm going to pay even MORE just to see this guy for an evaluation (let alone any sort of surgery/longer term treatment). All that kept going through my mind was Laurie the Insurance Warrior's articles about PPO's being nothing more than expensive HMO's....although, in this case, I'm about to be bent over by the physician before AETNA ever gets a crack at me. Now, I know this doesn't sound like much to some of you, but it's absolutely astounding me. And yet, on the other hand, I guess when you're at the top of the pecking order you can tell the insurance companies to pack sand with their lowball rates.

So, where does that leave me? Well, I'm awaiting response to see how much (if any) Aetna will cover. Figure I'll get his input, and see how much it jives with what I've already been told. Unfortunately, with all the research I've done on back issues (on my own, and around here), I'm not sure there's much they're going to offer. Tangentally, I recieved a call back from another surgeon's office today and was informed there was nothing he could offer me (based solely on reading a fax of my latest MRI....wow!). Figure I'll take it all in stride, and try to mentally prepare myself for the inevitable transition from semi-normalcy into reliance on pain meds. Sorry for sounding so down, but up until this point I had SOME hope that this would eventually get better (or at least plateau).....

Alan
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4/07:LBP + radiculopathy=severe L5-S1 herniation , 7/07:Micro-D, 08-09:Reherniation, 09-17: periodic residual symptoms (conservative modalities to maintain "stability" = prolotherapy, ESI/nerve blocks/facet injections, chiro, massage, phys ther), 7/17 pain in neck/right shoulder radiating into hand (no trauma involved), 7-10/17 Conservative treatment to date include physical therapy/dry-needling/facet-injections (C4/5 to C6/7). Researching surgical options should progression continue.
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Old 11-03-2010, 08:58 AM
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Alan,

Don't get too down just yet. So far you've tried to see one doctor in your area that is so popular that he doesn't have to take insurance, and then you've consulted one other doctor that for whatever reason doesn't want to perform the surgery. It is good practice to get multiple opinions anyway. He was just your first under your new insurance plan.

My bet is that Aetna will pay out of network rates (probably 70%) of what they deem to be "reasonable and customary" charges for his service, which leaves you with 100% of what Aetna says he should charge and what he actually charges. That could be a lot of dollar$.

Good luck, and please keep us posted.

Jeff
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