Re: HMO (in) Humane Mean Owners of Insurance Co's

[Guest guest]

Sorry to hear this. I fought against an HMO for more than a year.

Finally I exercised my option to change to another plan (I am so lucky

to have had that option). My HMO didn't even want me to talk to any

orthopedic surgeons except their one. Luckily I was able to get in

and talk to Dr. Mont and find out what the options were. Based on

that I finally switched plans and had the surgery a few weeks ago. I

still don't know how much the new insurance is going to pay or if they

are going to cause trouble. They are not permitted, under my

contract, to exclude pre-existing conditions.

Good luck to you,

RC2K Dr. Gross 3/24/04

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

If you are serious, may I suggest you buy a copy of " Total Hip

Arthroplasty For Dummies " at your local bookstore.

:-)

RC2K Dr. Gross 3/24/04

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

Hi ,

Talk to Lee Webb at Dr. Gross's office and see what she thinks. She may

also have you talk to the person in the office who handles their insurance

claims. I correspended and talked with Lee several months ago, and she and

all the office staff were always very friendly and helpful. They may know

what the usual drill is for HMO claims, and how to handle this to get

coveragel Maybe an explanation of the difficulty of your case will be

sufficient for the HMO. If not, I urge you to bite the bullet, and pay for

the Belgium option yourself ASAP. Depending on the current exchange rate,

it will cost about $15,000 including the airfare and the hotel bill. I know

it's frustrating to pay for insurance and then not have it cover what you

need, but this is your life and your health! I spent 9 months in needless

pain, all the while sustaining more hip damage and putting a strain on my

knees and back to compensate for my limp. The hardest decision was to just

give up on the insurance battle and get on with my life. I came very close

to losing so much bone that even Dr. De Smet would not have been able to do

my resurface.

I'm 6 weeks post-op now, and I haven't felt this good in years. I was

in constant pain 24/7 for months before my surgery.

Now, I still have a little bit of incision pain (especially after sitting

too long!) and some muscle pain, but nothing like before. Ultimately,

there's no better way to spend your money than on your quality of life.

Find a way to finance this if you have to. You're worth it. As someone in

this group told me when I was still caught up in the injustice of the

situation, " for about the price of a good used car you can have your life

back! "

Good luck with the HMO. Keep us posted, and don't let this take months.

Better to get (a little) drunk in Belgium with your new painless hip!

rBHR 3/3/04 De Smet

---- Original Message -----

To: surfacehippy >

Sent: Friday, April 16, 2004 7:35 PM

Subject: HMO (in) Humane Mean Owners of Insurance Co's

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is now

> going to take a long time & It hurts so bad, I am ready to get drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

>

>

>

>

>

>

>

[Guest guest]

Hi ,

Talk to Lee Webb at Dr. Gross's office and see what she thinks. She may

also have you talk to the person in the office who handles their insurance

claims. I correspended and talked with Lee several months ago, and she and

all the office staff were always very friendly and helpful. They may know

what the usual drill is for HMO claims, and how to handle this to get

coveragel Maybe an explanation of the difficulty of your case will be

sufficient for the HMO. If not, I urge you to bite the bullet, and pay for

the Belgium option yourself ASAP. Depending on the current exchange rate,

it will cost about $15,000 including the airfare and the hotel bill. I know

it's frustrating to pay for insurance and then not have it cover what you

need, but this is your life and your health! I spent 9 months in needless

pain, all the while sustaining more hip damage and putting a strain on my

knees and back to compensate for my limp. The hardest decision was to just

give up on the insurance battle and get on with my life. I came very close

to losing so much bone that even Dr. De Smet would not have been able to do

my resurface.

I'm 6 weeks post-op now, and I haven't felt this good in years. I was

in constant pain 24/7 for months before my surgery.

Now, I still have a little bit of incision pain (especially after sitting

too long!) and some muscle pain, but nothing like before. Ultimately,

there's no better way to spend your money than on your quality of life.

Find a way to finance this if you have to. You're worth it. As someone in

this group told me when I was still caught up in the injustice of the

situation, " for about the price of a good used car you can have your life

back! "

Good luck with the HMO. Keep us posted, and don't let this take months.

Better to get (a little) drunk in Belgium with your new painless hip!

rBHR 3/3/04 De Smet

---- Original Message -----

To: surfacehippy >

Sent: Friday, April 16, 2004 7:35 PM

Subject: HMO (in) Humane Mean Owners of Insurance Co's

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is now

> going to take a long time & It hurts so bad, I am ready to get drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

>

>

>

>

>

>

>

[Guest guest]

Pull your own strings, talk to Gross' office, get a referal, and

legitimize going out of state. Get it done! It can happen.

Keepyerchinnup!

Captain Amaze_O

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

Pull your own strings, talk to Gross' office, get a referal, and

legitimize going out of state. Get it done! It can happen.

Keepyerchinnup!

Captain Amaze_O

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

Pull your own strings, talk to Gross' office, get a referal, and

legitimize going out of state. Get it done! It can happen.

Keepyerchinnup!

Captain Amaze_O

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

:

I don't know if your HMO works the way mine did . . . but . . .

Your Primary Care Physician ( " PCP " ) may serve as the gatekeeper to all

other medical services. You must get a referral from your PCP to see

anyone else. In the case of my HMO, his was not the last word. He

" recommended " the referral and it then went through some kind of

review. They would respond to my PCP within 3 days (almost always

with a NO). I would then have to request a written copy of their

decision (which took another week to 10 days). Then I had the right

to appeal that decision (which was a process that took 45 days).

If your PCP is understanding, maybe you can get the referral. Mine

was very willing to do the referrals but the board that had to approve

them was not.

I would guess that the problem is not with going out-of-state it's

probably with going out-of-network. Do you know if your HMO contract

has any out-of-network benefits? Mine had none.

The best advice was to consult with Lee about how to approach this.

One angle might be to play to the one thing they understand - money.

A device with a hard bearing surface should last a long time - that

should equate to cost savings for them. A device with a large femoral

head should resist dislocation - that should equate to cost savings

for them. You probably want to stay away from the technical details

of resurfacing.

Again, the suggestion that you talk to Lee about how to pursue this

was a good one.

I feel for you - best of luck,

RC2K Dr. Gross 3/24/04

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

:

I don't know if your HMO works the way mine did . . . but . . .

Your Primary Care Physician ( " PCP " ) may serve as the gatekeeper to all

other medical services. You must get a referral from your PCP to see

anyone else. In the case of my HMO, his was not the last word. He

" recommended " the referral and it then went through some kind of

review. They would respond to my PCP within 3 days (almost always

with a NO). I would then have to request a written copy of their

decision (which took another week to 10 days). Then I had the right

to appeal that decision (which was a process that took 45 days).

If your PCP is understanding, maybe you can get the referral. Mine

was very willing to do the referrals but the board that had to approve

them was not.

I would guess that the problem is not with going out-of-state it's

probably with going out-of-network. Do you know if your HMO contract

has any out-of-network benefits? Mine had none.

The best advice was to consult with Lee about how to approach this.

One angle might be to play to the one thing they understand - money.

A device with a hard bearing surface should last a long time - that

should equate to cost savings for them. A device with a large femoral

head should resist dislocation - that should equate to cost savings

for them. You probably want to stay away from the technical details

of resurfacing.

Again, the suggestion that you talk to Lee about how to pursue this

was a good one.

I feel for you - best of luck,

RC2K Dr. Gross 3/24/04

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

:

I don't know if your HMO works the way mine did . . . but . . .

Your Primary Care Physician ( " PCP " ) may serve as the gatekeeper to all

other medical services. You must get a referral from your PCP to see

anyone else. In the case of my HMO, his was not the last word. He

" recommended " the referral and it then went through some kind of

review. They would respond to my PCP within 3 days (almost always

with a NO). I would then have to request a written copy of their

decision (which took another week to 10 days). Then I had the right

to appeal that decision (which was a process that took 45 days).

If your PCP is understanding, maybe you can get the referral. Mine

was very willing to do the referrals but the board that had to approve

them was not.

I would guess that the problem is not with going out-of-state it's

probably with going out-of-network. Do you know if your HMO contract

has any out-of-network benefits? Mine had none.

The best advice was to consult with Lee about how to approach this.

One angle might be to play to the one thing they understand - money.

A device with a hard bearing surface should last a long time - that

should equate to cost savings for them. A device with a large femoral

head should resist dislocation - that should equate to cost savings

for them. You probably want to stay away from the technical details

of resurfacing.

Again, the suggestion that you talk to Lee about how to pursue this

was a good one.

I feel for you - best of luck,

RC2K Dr. Gross 3/24/04

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

It's not, , but keep in mind that health insurers in any form

are for profit businesses and rarely care more about your individual

misery than their daily cash flow. Claims, especially for previously

uncovered procedures, will automatically be denied in the hope that

may give up trying right then and there. No matter the long term

benefit to you or them, they're purely short term thinkers when it

comes to reimbursement. Get a back up remedy in place, such as

Belgium, and don't spin your wheels more than your pain can handle.

Several Belgian hippies have reported success submitting claims after

surgery and long after a series of preop claims authorization denials.

Good luck!

Steve Vince

Bilat BHR De Smet jan 6, 2004

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is now

> going to take a long time & It hurts so bad, I am ready to get drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

It's not, , but keep in mind that health insurers in any form

are for profit businesses and rarely care more about your individual

misery than their daily cash flow. Claims, especially for previously

uncovered procedures, will automatically be denied in the hope that

may give up trying right then and there. No matter the long term

benefit to you or them, they're purely short term thinkers when it

comes to reimbursement. Get a back up remedy in place, such as

Belgium, and don't spin your wheels more than your pain can handle.

Several Belgian hippies have reported success submitting claims after

surgery and long after a series of preop claims authorization denials.

Good luck!

Steve Vince

Bilat BHR De Smet jan 6, 2004

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is now

> going to take a long time & It hurts so bad, I am ready to get drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

It's not, , but keep in mind that health insurers in any form

are for profit businesses and rarely care more about your individual

misery than their daily cash flow. Claims, especially for previously

uncovered procedures, will automatically be denied in the hope that

may give up trying right then and there. No matter the long term

benefit to you or them, they're purely short term thinkers when it

comes to reimbursement. Get a back up remedy in place, such as

Belgium, and don't spin your wheels more than your pain can handle.

Several Belgian hippies have reported success submitting claims after

surgery and long after a series of preop claims authorization denials.

Good luck!

Steve Vince

Bilat BHR De Smet jan 6, 2004

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is now

> going to take a long time & It hurts so bad, I am ready to get drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

> Hi ,

>

> Talk to Lee Webb at Dr. Gross's office and see what she

thinks. She may

> also have you talk to the person in the office who handles their

insurance

> claims. I correspended and talked with Lee several months ago,

and she and

> all the office staff were always very friendly and helpful. They

may know

> what the usual drill is for HMO claims, and how to handle this to

get

> coveragel Maybe an explanation of the difficulty of your case

will be

> sufficient for the HMO. If not, I urge you to bite the bullet,

and pay for

> the Belgium option yourself ASAP. Depending on the current

exchange rate,

> it will cost about $15,000 including the airfare and the hotel

bill. I know

> it's frustrating to pay for insurance and then not have it cover

what you

> need, but this is your life and your health! I spent 9 months in

needless

> pain, all the while sustaining more hip damage and putting a

strain on my

> knees and back to compensate for my limp. The hardest decision

was to just

> give up on the insurance battle and get on with my life. I came

very close

> to losing so much bone that even Dr. De Smet would not have been

able to do

> my resurface.

> I'm 6 weeks post-op now, and I haven't felt this good in

years. I was

> in constant pain 24/7 for months before my surgery.

> Now, I still have a little bit of incision pain (especially after

sitting

> too long!) and some muscle pain, but nothing like before.

Ultimately,

> there's no better way to spend your money than on your quality of

life.

> Find a way to finance this if you have to. You're worth it. As

someone in

> this group told me when I was still caught up in the injustice of

the

> situation, " for about the price of a good used car you can have

your life

> back! "

> Good luck with the HMO. Keep us posted, and don't let this

take months.

> Better to get (a little) drunk in Belgium with your new painless

hip!

>

>

> rBHR 3/3/04 De Smet

>

> ---- Original Message -----

> From: " steamboatskigirl "

> To: surfacehippy >

> Sent: Friday, April 16, 2004 7:35 PM

> Subject: HMO (in) Humane Mean Owners of Insurance

Co's

>

>

> > Hello everyone -

> >

> > Strange? I thought I sent this message 2 days ago, but I think

it

> > ended up in surf limbo somewhere....

> >

> > I have a local HMO for my insurance (Sloan's Lake/CBA), and when

I

> > scheduled my surgery date, they told Dr.Gross's office that they

> > need a written referral & a legitimate case for why I need to

travel

> > out of state.

> >

> > I somehow don't see this as a good sign.

> >

> > I'm really bummed, because working all this out seems like it is

now

> > going to take a long time & It hurts so bad, I am ready to get

drunk

> > & do it myself!

> >

> > Anyone have any advice?

> >

> > Thanks,

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

> Hi ,

>

> Talk to Lee Webb at Dr. Gross's office and see what she

thinks. She may

> also have you talk to the person in the office who handles their

insurance

> claims. I correspended and talked with Lee several months ago,

and she and

> all the office staff were always very friendly and helpful. They

may know

> what the usual drill is for HMO claims, and how to handle this to

get

> coveragel Maybe an explanation of the difficulty of your case

will be

> sufficient for the HMO. If not, I urge you to bite the bullet,

and pay for

> the Belgium option yourself ASAP. Depending on the current

exchange rate,

> it will cost about $15,000 including the airfare and the hotel

bill. I know

> it's frustrating to pay for insurance and then not have it cover

what you

> need, but this is your life and your health! I spent 9 months in

needless

> pain, all the while sustaining more hip damage and putting a

strain on my

> knees and back to compensate for my limp. The hardest decision

was to just

> give up on the insurance battle and get on with my life. I came

very close

> to losing so much bone that even Dr. De Smet would not have been

able to do

> my resurface.

> I'm 6 weeks post-op now, and I haven't felt this good in

years. I was

> in constant pain 24/7 for months before my surgery.

> Now, I still have a little bit of incision pain (especially after

sitting

> too long!) and some muscle pain, but nothing like before.

Ultimately,

> there's no better way to spend your money than on your quality of

life.

> Find a way to finance this if you have to. You're worth it. As

someone in

> this group told me when I was still caught up in the injustice of

the

> situation, " for about the price of a good used car you can have

your life

> back! "

> Good luck with the HMO. Keep us posted, and don't let this

take months.

> Better to get (a little) drunk in Belgium with your new painless

hip!

>

>

> rBHR 3/3/04 De Smet

>

> ---- Original Message -----

> From: " steamboatskigirl "

> To: surfacehippy >

> Sent: Friday, April 16, 2004 7:35 PM

> Subject: HMO (in) Humane Mean Owners of Insurance

Co's

>

>

> > Hello everyone -

> >

> > Strange? I thought I sent this message 2 days ago, but I think

it

> > ended up in surf limbo somewhere....

> >

> > I have a local HMO for my insurance (Sloan's Lake/CBA), and when

I

> > scheduled my surgery date, they told Dr.Gross's office that they

> > need a written referral & a legitimate case for why I need to

travel

> > out of state.

> >

> > I somehow don't see this as a good sign.

> >

> > I'm really bummed, because working all this out seems like it is

now

> > going to take a long time & It hurts so bad, I am ready to get

drunk

> > & do it myself!

> >

> > Anyone have any advice?

> >

> > Thanks,

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

> Hi ,

>

> Talk to Lee Webb at Dr. Gross's office and see what she

thinks. She may

> also have you talk to the person in the office who handles their

insurance

> claims. I correspended and talked with Lee several months ago,

and she and

> all the office staff were always very friendly and helpful. They

may know

> what the usual drill is for HMO claims, and how to handle this to

get

> coveragel Maybe an explanation of the difficulty of your case

will be

> sufficient for the HMO. If not, I urge you to bite the bullet,

and pay for

> the Belgium option yourself ASAP. Depending on the current

exchange rate,

> it will cost about $15,000 including the airfare and the hotel

bill. I know

> it's frustrating to pay for insurance and then not have it cover

what you

> need, but this is your life and your health! I spent 9 months in

needless

> pain, all the while sustaining more hip damage and putting a

strain on my

> knees and back to compensate for my limp. The hardest decision

was to just

> give up on the insurance battle and get on with my life. I came

very close

> to losing so much bone that even Dr. De Smet would not have been

able to do

> my resurface.

> I'm 6 weeks post-op now, and I haven't felt this good in

years. I was

> in constant pain 24/7 for months before my surgery.

> Now, I still have a little bit of incision pain (especially after

sitting

> too long!) and some muscle pain, but nothing like before.

Ultimately,

> there's no better way to spend your money than on your quality of

life.

> Find a way to finance this if you have to. You're worth it. As

someone in

> this group told me when I was still caught up in the injustice of

the

> situation, " for about the price of a good used car you can have

your life

> back! "

> Good luck with the HMO. Keep us posted, and don't let this

take months.

> Better to get (a little) drunk in Belgium with your new painless

hip!

>

>

> rBHR 3/3/04 De Smet

>

> ---- Original Message -----

> From: " steamboatskigirl "

> To: surfacehippy >

> Sent: Friday, April 16, 2004 7:35 PM

> Subject: HMO (in) Humane Mean Owners of Insurance

Co's

>

>

> > Hello everyone -

> >

> > Strange? I thought I sent this message 2 days ago, but I think

it

> > ended up in surf limbo somewhere....

> >

> > I have a local HMO for my insurance (Sloan's Lake/CBA), and when

I

> > scheduled my surgery date, they told Dr.Gross's office that they

> > need a written referral & a legitimate case for why I need to

travel

> > out of state.

> >

> > I somehow don't see this as a good sign.

> >

> > I'm really bummed, because working all this out seems like it is

now

> > going to take a long time & It hurts so bad, I am ready to get

drunk

> > & do it myself!

> >

> > Anyone have any advice?

> >

> > Thanks,

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

,

I fought with my HMO last year for coverage to go " out of network " .

It was very frustrating but it's worth a try. If you are

successful, it will be a lot less expensive than going to another

country or switching plans.

My case hinged around my proving that resurfacing was a " medical

necessity " (and the HMO defines what that means - pointed out to me

by the HMO's legal council during my hearing) and the fact that this

is an " FDA Investigational Study " . I had an OS in network give me a

written referal but he didn't layout for the HMO that resurfacing

was medically necessary for me. If you can get an OS with an open

mind that is in network to write a letter stating that resurfacing

is a medical necessity in order for you to maintain your " quality of

life " I think that it would be helpful.

I had Dr. Gross write that letter but he's performing the procedure

out of network and it doesn't carry as much weight with the HMO as

the most respected OS in the network.

My suggestion is to provide what they are asking for and if it

doesn't work, APPEAL. It doesn't cost you anything (although it is

time consuming) and who knows, you might get lucky.

You may also want to consider hiring a lawyer who has been

successful fighting medical insurance companies. In retrospect, I

think that would have helped my case.

If you can wait until the first device is approved here in the US it

might help your case (the mfr. of the Conserve Plus has filed an

application to the FDA for marketing approval - FDA has until around

June to either approve, deny or ask more questions). The only

drawback with approval is they may want to have it performed within

your network (most likely by a surgeon who has little or no

experience with resurfacing).

As someone else said, the insurance companies are in business to

make money. It costs them more if they have to pay a surgeon and

hospital that are outside of the network.

I switched to an HMO - POS (point of service) plan with the same

company that allowed me to go out of network and pay a 20% co-pay

along with 100% of what the insurance company didn't cover (or the

amount over their allowance). By the time we're finished with the

bills it will probably cost $10K - $11K.

If you choose to get drunk and do it yourself, I'd suggest that you

go the THR route as it's supposed to be an easier operation to

perform.

Good luck with whatever you decide,

Fred

Gross C2K 1/21/04

> Hello everyone -

>

> Strange? I thought I sent this message 2 days ago, but I think it

> ended up in surf limbo somewhere....

>

> I have a local HMO for my insurance (Sloan's Lake/CBA), and when I

> scheduled my surgery date, they told Dr.Gross's office that they

> need a written referral & a legitimate case for why I need to

travel

> out of state.

>

> I somehow don't see this as a good sign.

>

> I'm really bummed, because working all this out seems like it is

now

> going to take a long time & It hurts so bad, I am ready to get

drunk

> & do it myself!

>

> Anyone have any advice?

>

> Thanks,

[Guest guest]

,

I'm really stubborn, too. In fact, that's what allowed me to get so

caught up in the insurance battle that I almost stubborned myself out of

being a candidate for resurfacing! After my own experience, I would say

that if you're already needing crutches since February, and have been in

pain since December of last year, that's already a lot of needless pain.

Does Dr. Gross think you need to have a resurfacing done soon in order to

have enough good bone left to work with? If he doesn't feel resurfacing is

medically urgent, and you are willing to wait to see if his office can get

your claim approved on the first try, that might be the way to go.

Personally, I wouldn't even start the appeal process if I had it to do

again. They can and probably will drag this out for months. All the while,

you're in increasing pain, losing more bone, and putting stress on you knees

and back from your altered gait.

If you decide to go to Belgium, the hospital will be happy to put their

fee on a major credit card. If you arrange your financing before you

leave, you can pay off the entire amount when you return at a lower interest

rate than the credit card.

The hospital bill is 6,000 Euros or about $7,500 depending on the exchange

rate that day. Dr. De Smet requests 3 separate payments by wire transfer 3

weeks before your surgery or ASAP if your surgery is less than 3 weeks off.

I had never wired money before, so I had no clue how this worked, but since

the money was coming from a bank account, I figured that was where I'd

start! My bank wired the 3 payments and charged $18.00 each. Each one

required the same long form to be filled out. Then the teller entered all

the information I'd just written out into a computer for the transfer.

(Seems like it would have been easier to just enter it directly as I

dictated it, but whatever!)

The three payments totalled 4,500 Euros or about $5,625. Of this, 2,500

Euros ($3,125) was the surgeon's fee, which covers the surgery and followup

in hospital and at the HI, and 600 Euros ($750) and 1400 Euros ($1,750) were

clinic charges (physical therapy, dressing changes on site at the HI) and

administrative fees. These dollar estimates were based on an exchange rate

of 1 Euro = $1.25. The rate was about 1 Euro = $1.27 the day I was

transferring funds. I just checked the current exchange rate online, and

right now 1 Euro = $1.19320. Your 4500 Euro charge equals $5,369.40. The

6,000 Euro hospital bill would be $7,159.20.

Hope this helps. Let me know if I can be of any further help, and where

you are in the decision process.

Przygoda

rBHR 33/04 De Smet

P.S. I, too, prefer to think of my stubborn streak as perseverence!

HMO (in) Humane Mean Owners of Insurance

> Co's

> >

> >

> > > Hello everyone -

> > >

> > > Strange? I thought I sent this message 2 days ago, but I think

> it

> > > ended up in surf limbo somewhere....

> > >

> > > I have a local HMO for my insurance (Sloan's Lake/CBA), and when

> I

> > > scheduled my surgery date, they told Dr.Gross's office that they

> > > need a written referral & a legitimate case for why I need to

> travel

> > > out of state.

> > >

> > > I somehow don't see this as a good sign.

> > >

> > > I'm really bummed, because working all this out seems like it is

> now

> > > going to take a long time & It hurts so bad, I am ready to get

> drunk

> > > & do it myself!

> > >

> > > Anyone have any advice?

> > >

> > > Thanks,

> > >

> > >

> > >

> > >

> > >

> > >

> > >