I am looking over the bills I've received for my PAO. I thought you'd all be amused and/or appalled by some of these numbers. Note that I have not yet received a bill from the surgeon yet!
These numbers all represent pretend money in many ways. For example, I pay 20% co-pays on pretty much everything, but my "out of pocket maximum" is $1,500 per year, meaning that most covered, in-network charges I incur over $1,500 are paid by Aetna. I also have to pay a $350 deductible. Prescriptions have their own deductible. And, if I go "out of network," there are additional maximums and deductibles. All of my care to date has been "in network" with a few things just not covered by insurance at all, such as $600 for autologous and directed blood donations.
So far I've actually paid about $2,000 for out of pocket maximum, medical deductibles, and prescription deductibles. I have also paid about $3,200 for non-insured but necessary expenses that I would not have incurred without having a PAO (blood donations, assistive devices, vitamins, pool membership, hotel in Tacoma for family members, gas to and from Tacoma, meals in Tacoma.)
The total hospital bill (5 night stay in a private room which was billed as "semi-private" and a huge list of undisclosed "incidentals") is a whopping $109,000. The negotiated rate that Aetna paid is just over $30,000. The hospital had to make some margin of profit on the deal just to stay in business. That leads me to ask, what was the true cost? Had I paid this out of pocket with my 50% cash discount the hospital would have realized an additional $25,000 profit over what Aetna paid. Luckily I did NOT have to pay out of pocket, and really, how many people would have actually paid a bill like that despite signing a payment guarantee? I was prepared to pay if necessary but I realize most people could not afford to.
In addition to the hospital bill, the charge for the anesthesiologist was in the neighborhood of $3,000 (my cost = zero since insurance covered in full). Prescriptions were billed out at about $600; my co-pay was just under $200 ($150 of that just for Fragmin which is considered by my insurance plan to be a "specialized" drug). A huge supply of narcotics only cost me $20; that's a bargain considering what each pill sells for down at the bus mall on 82nd Street. Medical equipment was billed at $600 but this does not include the CPM machine since I have not yet seen that bill (my cost for equipment will be zero because insurance will cover it all). Various x-rays and lab tests were billed at a couple hundred dollars (again, my cost = zero).
I will probably go out of network for physical therapy (see my prior post), which means I'll be paying for much of that out of pocket, about $50 per visit. Aetna may add my PT to their network but I'm not holding my breath.
The bills keep rolling in. I'll publish a grand total in a future post.
Showing posts with label Aetna. Show all posts
Showing posts with label Aetna. Show all posts
Sunday, August 23, 2009
Monday, August 17, 2009
Let's get physical
I have been in search of a physical therapist who is conveniently located, takes my insurance, has worked with dancers/skaters, and has worked with PAO patients. The first three things are easy to find, but it seems none of the in-network PTs have ever worked with a PAO patient. This is not insurmountable, but I'd really prefer someone who has been there and done that. After all, this is NOT your grandmother's hip replacement, yadda yadda yadda, and I don't want the person responsible for my rehab to treat me just like the resurf and THR hippies (no offense to y'all).
I know there are many surgeons out there who don't even prescribe PT, but mine does and I think there are many things a good PT can do for me. It's not that I'm lacking in the motivation department, or that I don't know how to go to the gym and sweat. I just want some guidance. For example, they can point out that I'm limping and teach me how not to. Or, they can evaluate where my body parts might be out of alignment or unbalanced and show me how to fix it. These are all things that I might notice through trial and error, but I'd rather leave their diagnosis and cure to a trained professional. I know my body pretty well, but I don't claim to know how to fix it when it's broken.
I finally found someone out of network who has worked with not one, but TWO post-PAO patients. She clearly has a good understanding of the challenges I will face, and she said that her PAO patients both did remarkably well. I've made an appointment with her and will ask if I can contact the PAO patients as references. She is working on getting Aetna to add her to their network. Now all I need is clearance from Dr. Mayo to start PT at my follow-up appointment on the 25th. Bones, heal thyselves!
I know there are many surgeons out there who don't even prescribe PT, but mine does and I think there are many things a good PT can do for me. It's not that I'm lacking in the motivation department, or that I don't know how to go to the gym and sweat. I just want some guidance. For example, they can point out that I'm limping and teach me how not to. Or, they can evaluate where my body parts might be out of alignment or unbalanced and show me how to fix it. These are all things that I might notice through trial and error, but I'd rather leave their diagnosis and cure to a trained professional. I know my body pretty well, but I don't claim to know how to fix it when it's broken.
I finally found someone out of network who has worked with not one, but TWO post-PAO patients. She clearly has a good understanding of the challenges I will face, and she said that her PAO patients both did remarkably well. I've made an appointment with her and will ask if I can contact the PAO patients as references. She is working on getting Aetna to add her to their network. Now all I need is clearance from Dr. Mayo to start PT at my follow-up appointment on the 25th. Bones, heal thyselves!
Thursday, June 18, 2009
I just won the lottery!
Well, I might as well have. Aetna pre-approved my surgery.
It's actually kind of pathetic that this is something to celebrate. That's right, my insurance company is actually going to PAY for surgery that will allow me to walk without pain again while allowing me to preserve my own hip joint. You would think that would be a no brainer, but I have been worried about it for the past 8 months, because the first thing they told me when I walked into Dr. Mayo's office was, "Insurance is not going to pay for this, and it's going to cost you $300,000."
(That amount was inflated of course, because the hospital gives you a 50% discount when you pay cash. But still. I just don't have that kind of change sitting in my cookie jar.)
I won't really believe it until I get the letter from Aetna; Keri from Dr. Mayo's office e-mailed me with the news today and she said I should expect a letter soon. Meanwhile I will be pondering which house projects to do now that there is actually money to pay for them. I think this means I can finally remodel my kitchen. Bye bye, bright blue kitchen countertops with burn marks! Bye bye, refrigerator sticking out into the middle of the room! Bye bye, ancient microwave whose handle is held on with duct tape! As soon as I recover, you are all OUTTA HERE!
It's actually kind of pathetic that this is something to celebrate. That's right, my insurance company is actually going to PAY for surgery that will allow me to walk without pain again while allowing me to preserve my own hip joint. You would think that would be a no brainer, but I have been worried about it for the past 8 months, because the first thing they told me when I walked into Dr. Mayo's office was, "Insurance is not going to pay for this, and it's going to cost you $300,000."
(That amount was inflated of course, because the hospital gives you a 50% discount when you pay cash. But still. I just don't have that kind of change sitting in my cookie jar.)
I won't really believe it until I get the letter from Aetna; Keri from Dr. Mayo's office e-mailed me with the news today and she said I should expect a letter soon. Meanwhile I will be pondering which house projects to do now that there is actually money to pay for them. I think this means I can finally remodel my kitchen. Bye bye, bright blue kitchen countertops with burn marks! Bye bye, refrigerator sticking out into the middle of the room! Bye bye, ancient microwave whose handle is held on with duct tape! As soon as I recover, you are all OUTTA HERE!
Friday, May 1, 2009
Dating Dilemma
Yesterday we closed on our house re-finance. This means we took a bunch of equity out of our house in order to pay for my two surgeries. We also got a hell of a nice interest rate on our mortgage (4.75%, yippee), so we feel pretty good about that part of it. Not so good about having to raid essentially all of my non-retirement life savings in order to pay for surgery, of course.
Since I’m now funded, in case Aetna doesn’t want to play nice, I talked to the surgeon’s office today about getting an exact date in July. If I get the date I want (July 1), that’s only a bit over 8 weeks away, and there is so much to do between now and then.
They replied that they are “not ready” to schedule July because they are “not sure what they are doing quite yet.” Huh? Does that mean they may or may not be around in July? I want to have confidence in the people who will be cutting my pelvis apart and screwing it back together. I don’t have high confidence in people who are “not sure what they are doing.”
This answer also ticks me off. Do they not realize that I need to schedule time off work (and frankly, it’s not going to be easy for those at my office when I’m gone), file papers for STD and FMLA, get a bye on my coveted downtown parking spot, order a hospital bed for my home, order other post-surgical necessities, get a hotel room in Tacoma for the night before surgery, donate blood for myself (twice), get an appointment for a pre-surgery physical with my GP (who normally has a THREE MONTH lead time), etc., etc., etc. These are just the things I can think of off the top of my head.
I know doctors put a premium on nobody’s time but their own (no offense intended, any MDs that are reading this, but you know I’m right). That is why you can wait an hour and a half to see a doctor for 20 minutes, and there is no guilt or remorse shown by the doc or the staff. So perhaps this surgery scheduling is done last minute, so that I can scramble to get everything done, because the surgeon doesn’t believe that I have a life outside of their operating table to deal with beforehand.
Yes, I am feeling pissy. I have been recently promoted at work, and so I’m working a lot of hours and taking on a lot of new responsibility, all of which will be put on hold somehow for 6 – 8 weeks starting in July, which is just around the corner. I have to get everything in order with my staff and projects before then. I am doing some traveling to judge and for vacation, so I’m not going to be at anyone’s beck and call to just run on down to the blood donation center. I have scheduled a week-long visit from my stepdaughter, who I haven’t seen in a couple of years. My stepson is graduating from high school, and we are having a party. And on, and on, and on, the same list of real-life things to do that any of my hip sisters probably had before their surgeries as well. I will be putting most of my life on hold post-surgery, as will my husband, and my mother, who has promised to stay with me during the day while my husband is at work. Other family members and friends have been equally generous with their future time.
I am a project manager by trade and temperament. I need a time line. I need a countdown. I am at odds with nothing to plan toward except a vague “July.” I need a surgery date.
Since I’m now funded, in case Aetna doesn’t want to play nice, I talked to the surgeon’s office today about getting an exact date in July. If I get the date I want (July 1), that’s only a bit over 8 weeks away, and there is so much to do between now and then.
They replied that they are “not ready” to schedule July because they are “not sure what they are doing quite yet.” Huh? Does that mean they may or may not be around in July? I want to have confidence in the people who will be cutting my pelvis apart and screwing it back together. I don’t have high confidence in people who are “not sure what they are doing.”
This answer also ticks me off. Do they not realize that I need to schedule time off work (and frankly, it’s not going to be easy for those at my office when I’m gone), file papers for STD and FMLA, get a bye on my coveted downtown parking spot, order a hospital bed for my home, order other post-surgical necessities, get a hotel room in Tacoma for the night before surgery, donate blood for myself (twice), get an appointment for a pre-surgery physical with my GP (who normally has a THREE MONTH lead time), etc., etc., etc. These are just the things I can think of off the top of my head.
I know doctors put a premium on nobody’s time but their own (no offense intended, any MDs that are reading this, but you know I’m right). That is why you can wait an hour and a half to see a doctor for 20 minutes, and there is no guilt or remorse shown by the doc or the staff. So perhaps this surgery scheduling is done last minute, so that I can scramble to get everything done, because the surgeon doesn’t believe that I have a life outside of their operating table to deal with beforehand.
Yes, I am feeling pissy. I have been recently promoted at work, and so I’m working a lot of hours and taking on a lot of new responsibility, all of which will be put on hold somehow for 6 – 8 weeks starting in July, which is just around the corner. I have to get everything in order with my staff and projects before then. I am doing some traveling to judge and for vacation, so I’m not going to be at anyone’s beck and call to just run on down to the blood donation center. I have scheduled a week-long visit from my stepdaughter, who I haven’t seen in a couple of years. My stepson is graduating from high school, and we are having a party. And on, and on, and on, the same list of real-life things to do that any of my hip sisters probably had before their surgeries as well. I will be putting most of my life on hold post-surgery, as will my husband, and my mother, who has promised to stay with me during the day while my husband is at work. Other family members and friends have been equally generous with their future time.
I am a project manager by trade and temperament. I need a time line. I need a countdown. I am at odds with nothing to plan toward except a vague “July.” I need a surgery date.
Tuesday, March 17, 2009
My Countdown
I am getting close to the "three months until surgery" countdown. Up until now my surgery was a thing of the future; nothing to worry about because it was so far away.
As I updated my calendar today, I realized that if my surgery is scheduled for the first week in July (exact date can’t be finalized until May), I have about 3 and a half months left until the day of. And prior to that, a lot of scary things are going to happen in rapid succession such that I really can’t ignore them any more:
~Three autologous blood donations: For someone with tiny rubbery veins, giving any blood is a major trauma. When people say, “it’s just a simple blood donation,” I want to slap them. The thought of giving a pint on three different occasions sounds like 30 minutes of brutal digging around in my inner arms for a reluctant vessel followed by 90 minutes of slow-trickling horror for each donation.
~Physical by my GP: And guess what, they are going to take more blood at this appointment too to make sure I’m healthy. My veins are already retreating deeper into my body in rebellion.
~Pre-certification with insurance: Almost as horrifying as giving blood. I already know the answer is going to be "no" but we're going to ask again just for kicks.
~Pre-operative appointment with hospital/surgeon: They go over what to expect in surgery, I sign a bunch of papers, they take final x-rays, etc. I don’t think they take any more blood, but perhaps the joke will be on me. As I see it, this is my last chance to chicken out.
~Packing for hospital: Packing is not my forte as I’ve never mastered the concept of “traveling light.” Based on the advice of other hipchicks, I don’t think I need much. Ipod, hygiene items and something to wear home that is a size “large,” since I’ll be all swollen, should do it. I think underwear is optional in the hospital so I'm going al fresco. That should keep the mean physical therapists away.
~Checking in for surgery: The first thing they will do is insert an IV to sedate me. Enough with the veins already! Good luck finding one! HAHAHAHAHA!
(As you can see, my attitude needs a bit of adjusting over the next several months.)
I have been staring at my right upper leg a lot while in the shower or otherwise undressed. Taking a good gander at what it looks like now, before the big scar that I’ll wear forever after July. Not that my leg is so great looking now, but I have this nostalgic urge to take a picture for posterity. I’m not sure why it’s so important for me to document my pre-surgery body; I never wanted documentation of it before. It's not something I'll post on the blog since it feels too personal. However, once it's all cut open and gross, it's fair game for posting. So you can all look forward to gory scar photos galore - that's a promise.
As I updated my calendar today, I realized that if my surgery is scheduled for the first week in July (exact date can’t be finalized until May), I have about 3 and a half months left until the day of. And prior to that, a lot of scary things are going to happen in rapid succession such that I really can’t ignore them any more:
~Three autologous blood donations: For someone with tiny rubbery veins, giving any blood is a major trauma. When people say, “it’s just a simple blood donation,” I want to slap them. The thought of giving a pint on three different occasions sounds like 30 minutes of brutal digging around in my inner arms for a reluctant vessel followed by 90 minutes of slow-trickling horror for each donation.
~Physical by my GP: And guess what, they are going to take more blood at this appointment too to make sure I’m healthy. My veins are already retreating deeper into my body in rebellion.
~Pre-certification with insurance: Almost as horrifying as giving blood. I already know the answer is going to be "no" but we're going to ask again just for kicks.
~Pre-operative appointment with hospital/surgeon: They go over what to expect in surgery, I sign a bunch of papers, they take final x-rays, etc. I don’t think they take any more blood, but perhaps the joke will be on me. As I see it, this is my last chance to chicken out.
~Packing for hospital: Packing is not my forte as I’ve never mastered the concept of “traveling light.” Based on the advice of other hipchicks, I don’t think I need much. Ipod, hygiene items and something to wear home that is a size “large,” since I’ll be all swollen, should do it. I think underwear is optional in the hospital so I'm going al fresco. That should keep the mean physical therapists away.
~Checking in for surgery: The first thing they will do is insert an IV to sedate me. Enough with the veins already! Good luck finding one! HAHAHAHAHA!
(As you can see, my attitude needs a bit of adjusting over the next several months.)
I have been staring at my right upper leg a lot while in the shower or otherwise undressed. Taking a good gander at what it looks like now, before the big scar that I’ll wear forever after July. Not that my leg is so great looking now, but I have this nostalgic urge to take a picture for posterity. I’m not sure why it’s so important for me to document my pre-surgery body; I never wanted documentation of it before. It's not something I'll post on the blog since it feels too personal. However, once it's all cut open and gross, it's fair game for posting. So you can all look forward to gory scar photos galore - that's a promise.
Wednesday, March 11, 2009
It's the economy, stupid
Today I went to the rink and solo'd the Austrian, Cha Cha Congelado, and Ravensburger. I made up a new hydroblade/lunge move which I think is sort of cool. It's pretty much business as usual on the ice now that I'm into the Aleve. The minute I get off the ice my hips remind me that I can't walk very well, but for that hour at lunchtime I am just another skater on the ice.
Tonight we filled out the paperwork to refinance our house in order to take out enough money to pay for two PAO surgeries. Now is the right time - rates ticked down today, we are both employed, and our house is probably losing value on paper every day.
I've decided not to buy new boots. They are a "want" and not a "need," and in this economy that's a key distinction. When you are paying for surgical reconstruction of your body parts, there aren't many other things you can justify needing quite as much.
Tonight we filled out the paperwork to refinance our house in order to take out enough money to pay for two PAO surgeries. Now is the right time - rates ticked down today, we are both employed, and our house is probably losing value on paper every day.
I've decided not to buy new boots. They are a "want" and not a "need," and in this economy that's a key distinction. When you are paying for surgical reconstruction of your body parts, there aren't many other things you can justify needing quite as much.
Wednesday, December 3, 2008
It's official ...
I'm depressed.
I met with a counselor from my employer’s EAP on Monday. She told me that I am “grieving,” that my response is normal, and that it is going to take a long time to come to terms with things, accept them, and transition to my new life circumstances. I have been going through all the classic phases of grief – anger, denial, bargaining, depression, bitchiness, crankiness, sarcasm, uncontrolled swearing, and whininess. OK, see, I still have my sense of humor. Kind of.
It was good to have a professional validate my feelings. It’s OK for me to feel crappy. If anyone tells me that “it will be all right” or “other people have it much worse than I do,” I have a right to slap them silly and walk away. I know other people have it much worse than I do. That doesn’t mean that I don’t have a right to feel pissed off about my own rather crappy situation.
Throwing fuel on the fire, I’ve been in contact with my surgeon’s office trying to understand WHY Aetna doesn’t cover PAO. They have not given me a very good reason and I need to understand so I can take action. In typical condescending doctor’s office speak, they told me to butt out and let them handle it. They also told me, in exactly these words, that I am “not the only patient feeling the financial pressures.” Duh. My response was that I am operating on the concept of "you have to look out for yourself and your own health care because nobody else will." It’s not that I don’t want to help all of the other people feeling the financial pressures out there, but right now I can only fight for myself. It's called the survival instinct.
So who out there is curious about why Aetna denies PAOs? It’s not what you think. No, it's not that they can't spell "dysplasia." It’s not that they don’t like people who walk funny. It’s not even that there haven’t been enough research studies done. No, according to what I’m hearing, it’s because there is no procedure code for this operation. Doctors bill it using the code 27299, which means “unlisted procedure.” And, seeing that it’s "unlisted," Aetna promptly denies it.
What? Are you kidding me? This has to be the most asinine thing I have ever heard. Does this mean they don’t even read the file to find out what was done? They see that something “unlisted” was done and they just say NO? Please, give me a break. Based on all of the hip women I know, quite a few of these procedures are being done. Can’t the insurers and doctors, ahem, let’s see, I need to think really hard about this because I’m not as smart as they are… can’t they just CREATE A CODE????
WAIT, I know, maybe it’s a computer programming issue. Maybe the computers need the codes to be 5 digits, and all of the digits between 00000 and 99999 have already been assigned. That must be it. We’re out of codes! There are no more! So, medical scientists, you might as well stop doing any research or coming up with new operations and procedures, because when it comes to coding them you are SOL.
Of course I don’t really think that’s the issue, but I can’t comprehend what the issue might actually be. Someone help me out here. How fucking difficult can it be to create a 5-digit number?
The doctor’s office also told me that they won’t schedule any more surgeries until they either have authorization in hand from the insurance company OR the patient signs an agreement up front promising to pay cash for the surgery (at the bargain cash price of $70,000 for each hip). I told them to keep my July date and that yes, I’d pay cash if I had to. Send me the agreement and I'll sign it.
OK, so after this news, I decided it was time for the icing on the cake of my day … looking at my retirement funds and figuring out if I have enough money to pay for this. My retirement funds have taken a huge hit. I guess that should not be news to anyone reading this since I've recently discovered that "I am not the only one feeling the financial pressures." Could the timing for this be any worse? We're in the middle of the worst recession since perhaps the great depression and I need to sell investments?
All three of my retirement vehicles are down, way down, but the good news is that if I cash out right now, the funds I have accumulated as a result of the last 25 years of living frugally so that I can fully fund my retirement will be enough to pay for two surgeries, with a little left over to buy some new underwear. My life savings can get me my PAO. And, by July of next year, who knows, the market may go up!! Or, it may go down and I'll have to forego the underwear!! I have no idea!!
Just when I thought the day could not get any worse, I talked to H.R. at my employer about the logistics for taking a hardship withdrawal from my 401(k). I explained the situation. I told them that I was not pleased with our medical plan's policies. Here, verbatim for your amusement, is their reply.
“Terri:
I'm so sorry---it sounds like a difficult time. {EDITOR'S NOTE: NO KIDDING}
It's true medical plans do not cover all services. The good news is that according to our benchmark surveys, most employers have increased deductibles, premiums and co-pays this year. Our plans have none of these changes this year. While the plans won't cover everything, we're working hard to help you maintain the best coverage possible.”
What, medical plans do not cover all services? No Shit. It’s not like I’m asking them to pay for botox injections, for crying out loud. This is a real surgery, for a real condition, causing real pain and disability. It is not elective. It is not experimental. It is not optional for me.
But thanks guys, thanks for the great news! I’ll sleep so much better at night knowing that my deductibles, premiums and co-pays will not be increasing this year, even though the plan won’t cover everything … in fact, the plan won’t cover ANYTHING that I need, but at least it won't cost me more. And best of all, I GET THE BEST COVERAGE POSSIBLE. Yee haw! Party time! Pardon me while I PUKE and SCREAM and CRY and SWEAR.
It’s all part of that grieving process I’m going through.
I met with a counselor from my employer’s EAP on Monday. She told me that I am “grieving,” that my response is normal, and that it is going to take a long time to come to terms with things, accept them, and transition to my new life circumstances. I have been going through all the classic phases of grief – anger, denial, bargaining, depression, bitchiness, crankiness, sarcasm, uncontrolled swearing, and whininess. OK, see, I still have my sense of humor. Kind of.
It was good to have a professional validate my feelings. It’s OK for me to feel crappy. If anyone tells me that “it will be all right” or “other people have it much worse than I do,” I have a right to slap them silly and walk away. I know other people have it much worse than I do. That doesn’t mean that I don’t have a right to feel pissed off about my own rather crappy situation.
Throwing fuel on the fire, I’ve been in contact with my surgeon’s office trying to understand WHY Aetna doesn’t cover PAO. They have not given me a very good reason and I need to understand so I can take action. In typical condescending doctor’s office speak, they told me to butt out and let them handle it. They also told me, in exactly these words, that I am “not the only patient feeling the financial pressures.” Duh. My response was that I am operating on the concept of "you have to look out for yourself and your own health care because nobody else will." It’s not that I don’t want to help all of the other people feeling the financial pressures out there, but right now I can only fight for myself. It's called the survival instinct.
So who out there is curious about why Aetna denies PAOs? It’s not what you think. No, it's not that they can't spell "dysplasia." It’s not that they don’t like people who walk funny. It’s not even that there haven’t been enough research studies done. No, according to what I’m hearing, it’s because there is no procedure code for this operation. Doctors bill it using the code 27299, which means “unlisted procedure.” And, seeing that it’s "unlisted," Aetna promptly denies it.
What? Are you kidding me? This has to be the most asinine thing I have ever heard. Does this mean they don’t even read the file to find out what was done? They see that something “unlisted” was done and they just say NO? Please, give me a break. Based on all of the hip women I know, quite a few of these procedures are being done. Can’t the insurers and doctors, ahem, let’s see, I need to think really hard about this because I’m not as smart as they are… can’t they just CREATE A CODE????
WAIT, I know, maybe it’s a computer programming issue. Maybe the computers need the codes to be 5 digits, and all of the digits between 00000 and 99999 have already been assigned. That must be it. We’re out of codes! There are no more! So, medical scientists, you might as well stop doing any research or coming up with new operations and procedures, because when it comes to coding them you are SOL.
Of course I don’t really think that’s the issue, but I can’t comprehend what the issue might actually be. Someone help me out here. How fucking difficult can it be to create a 5-digit number?
The doctor’s office also told me that they won’t schedule any more surgeries until they either have authorization in hand from the insurance company OR the patient signs an agreement up front promising to pay cash for the surgery (at the bargain cash price of $70,000 for each hip). I told them to keep my July date and that yes, I’d pay cash if I had to. Send me the agreement and I'll sign it.
OK, so after this news, I decided it was time for the icing on the cake of my day … looking at my retirement funds and figuring out if I have enough money to pay for this. My retirement funds have taken a huge hit. I guess that should not be news to anyone reading this since I've recently discovered that "I am not the only one feeling the financial pressures." Could the timing for this be any worse? We're in the middle of the worst recession since perhaps the great depression and I need to sell investments?
All three of my retirement vehicles are down, way down, but the good news is that if I cash out right now, the funds I have accumulated as a result of the last 25 years of living frugally so that I can fully fund my retirement will be enough to pay for two surgeries, with a little left over to buy some new underwear. My life savings can get me my PAO. And, by July of next year, who knows, the market may go up!! Or, it may go down and I'll have to forego the underwear!! I have no idea!!
Just when I thought the day could not get any worse, I talked to H.R. at my employer about the logistics for taking a hardship withdrawal from my 401(k). I explained the situation. I told them that I was not pleased with our medical plan's policies. Here, verbatim for your amusement, is their reply.
“Terri:
I'm so sorry---it sounds like a difficult time. {EDITOR'S NOTE: NO KIDDING}
It's true medical plans do not cover all services. The good news is that according to our benchmark surveys, most employers have increased deductibles, premiums and co-pays this year. Our plans have none of these changes this year. While the plans won't cover everything, we're working hard to help you maintain the best coverage possible.”
What, medical plans do not cover all services? No Shit. It’s not like I’m asking them to pay for botox injections, for crying out loud. This is a real surgery, for a real condition, causing real pain and disability. It is not elective. It is not experimental. It is not optional for me.
But thanks guys, thanks for the great news! I’ll sleep so much better at night knowing that my deductibles, premiums and co-pays will not be increasing this year, even though the plan won’t cover everything … in fact, the plan won’t cover ANYTHING that I need, but at least it won't cost me more. And best of all, I GET THE BEST COVERAGE POSSIBLE. Yee haw! Party time! Pardon me while I PUKE and SCREAM and CRY and SWEAR.
It’s all part of that grieving process I’m going through.
Saturday, November 29, 2008
I’m over 40 … and my timing stinks
A new study was published which concludes that the outcome of PAO for patients over 40 is “not as good as” the outcome of total hip replacements. While it doesn’t say the outcome with PAO is “bad,” for an insurance company this is denial fodder worth its weight in gold.
Thanks guys, please kick me while I’m down.
As of November 1st, my insurance company, along with most others, has unilaterally decided not to pay for PAOs. This probably means that they WILL pay for some, if you make a really great case on appeal, but that by and large they consider this rare operation, which has helped women for 30 years, to be “investigational.” Not enough large studies have been done. Hmmm, how many is “enough”? There are quite a few small studies that I’ve read, but how can anyone do a large study when this surgery is so rare? This isn’t like diabetes or heart disease – run of the mill maladies which every Tom, Dick and Harry seems to have nowadays. And oh, by the way, Tom, Dick and Harry probably don’t have hip dysplasia because the vast majority of people with this condition are WOMEN. We all know what whiners women are … with their subjective complaints and all. Those women, they want special, expensive surgery for all their silly little problems … we big insurers need to let them know that we know what’s best for them!
Believe me, if I could have a total hip replacement or resurfacing instead of a PAO I’d be overjoyed. Recovery time for THR is short, and one is only in the hospital for a couple of days. I’d be walking and full weight bearing the day after surgery, and probably skating again within months. Not that THR is a cakewalk, but compared to PAO it’s “hip surgery lite.”
The problem is that my dysplasia is on the severe side, and it’s coupled with severe anteversion. THRs are not designed for people built like me. They, and their cousin the hip resurfacing, are designed for people whose hips are fairly normal in mechanical construction, with perhaps small abnormalities, but which are diseased or worn out. While there is a “dysplasia cap” available for hip resurfacing, again, it is not designed for severe cases. Two experts have now told me that my best course of action is PAO, based on the severity of my mechanical imbalance and the fact that my hip joint is basically healthy. Why would I remove and replace a healthy joint! Why would anyone do that? It seems obvious to me that correcting the structural imbalance, preserving the joint, and avoiding multiple revision surgeries is my best course of action. I’m seeking a third opinion. How many expert opinions do I need to override Aetna’s blanket policy?
I will add that I am not your typical 45 year old. I like to think that I am in better physical shape than most. I am not overweight. I am very muscular. I have exercised all my life. What about the over 40 patients in the new study? How many of them were like me? Is the only thing we have in common that we are "middle aged"? Yes, I am over 40, but my life isn’t over yet. I’m not ready to take up knitting or lawn bowling. MY PERFECTLY HEALTHY HIP JOINT SPACES DO NOT NEED TO BE REPLACED … that is not my problem, oh stupid insurance company flunkie reading my file. What I need is better femoral coverage. Isn’t the solution obvious?
Thanks guys, please kick me while I’m down.
As of November 1st, my insurance company, along with most others, has unilaterally decided not to pay for PAOs. This probably means that they WILL pay for some, if you make a really great case on appeal, but that by and large they consider this rare operation, which has helped women for 30 years, to be “investigational.” Not enough large studies have been done. Hmmm, how many is “enough”? There are quite a few small studies that I’ve read, but how can anyone do a large study when this surgery is so rare? This isn’t like diabetes or heart disease – run of the mill maladies which every Tom, Dick and Harry seems to have nowadays. And oh, by the way, Tom, Dick and Harry probably don’t have hip dysplasia because the vast majority of people with this condition are WOMEN. We all know what whiners women are … with their subjective complaints and all. Those women, they want special, expensive surgery for all their silly little problems … we big insurers need to let them know that we know what’s best for them!
Believe me, if I could have a total hip replacement or resurfacing instead of a PAO I’d be overjoyed. Recovery time for THR is short, and one is only in the hospital for a couple of days. I’d be walking and full weight bearing the day after surgery, and probably skating again within months. Not that THR is a cakewalk, but compared to PAO it’s “hip surgery lite.”
The problem is that my dysplasia is on the severe side, and it’s coupled with severe anteversion. THRs are not designed for people built like me. They, and their cousin the hip resurfacing, are designed for people whose hips are fairly normal in mechanical construction, with perhaps small abnormalities, but which are diseased or worn out. While there is a “dysplasia cap” available for hip resurfacing, again, it is not designed for severe cases. Two experts have now told me that my best course of action is PAO, based on the severity of my mechanical imbalance and the fact that my hip joint is basically healthy. Why would I remove and replace a healthy joint! Why would anyone do that? It seems obvious to me that correcting the structural imbalance, preserving the joint, and avoiding multiple revision surgeries is my best course of action. I’m seeking a third opinion. How many expert opinions do I need to override Aetna’s blanket policy?
I will add that I am not your typical 45 year old. I like to think that I am in better physical shape than most. I am not overweight. I am very muscular. I have exercised all my life. What about the over 40 patients in the new study? How many of them were like me? Is the only thing we have in common that we are "middle aged"? Yes, I am over 40, but my life isn’t over yet. I’m not ready to take up knitting or lawn bowling. MY PERFECTLY HEALTHY HIP JOINT SPACES DO NOT NEED TO BE REPLACED … that is not my problem, oh stupid insurance company flunkie reading my file. What I need is better femoral coverage. Isn’t the solution obvious?
Wednesday, November 12, 2008
Sticker Shock
I got my insurance recap for the visit to Dr. Mayo’s office. A few hundred dollars for the consult, a few hundred for the x-rays, and a whopping $1,999 for the CT scan.
I guess I was expecting a large bill, but not quite that much. Since I’m paying out of pocket I am experiencing a wee bit of sticker shock. It’s a good thing we didn’t decide to renovate the kitchen this year! I needed a CT scan far more than that 36” range with double oven.
When Perry and I decided to do the high deductible health care plan last year, we thought it was perfect for us. We are healthy and pretty much never go to the doctor. Wellness was covered 100%, and that’s the only thing we ever utilized. Why pay high premiums when you don’t need to?
So last year we were happy with our decision to go on the high deductible plan. And this year too, until August, when I became the proud owner of an expensive medical condition. I’m just about to hit my $3,000 deductible, but not quite … unless something else unexpected comes along before the end of the calendar year, but let’s hope not.
I think it’s good that as a consumer I’m forced to know what health care “really costs.” That prevents me from doing stupid things, like going to the emergency room when I stub my toe or eating fast food every day. I already take responsibility for my body and my health but I know some people don’t, so I guess truth in billing is a good thing.
The CT scan was about 10 minutes (after more than an hour wait) of being put into a donut-shaped machine and holding really still. I know it’s expensive because the technicians are highly trained and have to calculate a whole bunch of variances based on what the CT scan spits out, and there were two of them, and the machine’s expensive, and it uses a lot of energy. I’m not disputing a couple of grand (and I’m happy to pay it since it proved I didn’t need to have a second surgery on each leg – the CT scan was much cheaper and easier to recover from).
But I suspect this is a harbinger of more shocking bills to come, so I am bracing myself. Since it’s open enrollment time, I’m also changing back to the more expensive health care plan offered by my employer. Even though I know Aetna is going to initially refuse to pay for my surgeries until I appeal and eventually threaten to sue them, I would like to know that at the end of the day my maximum out of pocket and deductibles will be lower. Guess it’s OK to start eating more fast food.
I guess I was expecting a large bill, but not quite that much. Since I’m paying out of pocket I am experiencing a wee bit of sticker shock. It’s a good thing we didn’t decide to renovate the kitchen this year! I needed a CT scan far more than that 36” range with double oven.
When Perry and I decided to do the high deductible health care plan last year, we thought it was perfect for us. We are healthy and pretty much never go to the doctor. Wellness was covered 100%, and that’s the only thing we ever utilized. Why pay high premiums when you don’t need to?
So last year we were happy with our decision to go on the high deductible plan. And this year too, until August, when I became the proud owner of an expensive medical condition. I’m just about to hit my $3,000 deductible, but not quite … unless something else unexpected comes along before the end of the calendar year, but let’s hope not.
I think it’s good that as a consumer I’m forced to know what health care “really costs.” That prevents me from doing stupid things, like going to the emergency room when I stub my toe or eating fast food every day. I already take responsibility for my body and my health but I know some people don’t, so I guess truth in billing is a good thing.
The CT scan was about 10 minutes (after more than an hour wait) of being put into a donut-shaped machine and holding really still. I know it’s expensive because the technicians are highly trained and have to calculate a whole bunch of variances based on what the CT scan spits out, and there were two of them, and the machine’s expensive, and it uses a lot of energy. I’m not disputing a couple of grand (and I’m happy to pay it since it proved I didn’t need to have a second surgery on each leg – the CT scan was much cheaper and easier to recover from).
But I suspect this is a harbinger of more shocking bills to come, so I am bracing myself. Since it’s open enrollment time, I’m also changing back to the more expensive health care plan offered by my employer. Even though I know Aetna is going to initially refuse to pay for my surgeries until I appeal and eventually threaten to sue them, I would like to know that at the end of the day my maximum out of pocket and deductibles will be lower. Guess it’s OK to start eating more fast food.
Thursday, November 6, 2008
Mystery Muscles
Last night I did some of the PT exercises I’d read about on another hip chick’s blog. I suppose I should go to physical therapy myself; my insurance allegedly covers it at 80% after I satisfy my $3,000 deductible. But I thought I’d try the hip strengthening exercises and just see what gives.
I am shocked, SHOCKED to find out just how weak some of my muscles are, despite skating. I knew which muscles were overdeveloped, but wasn’t aware until now how many were underdeveloped and underutilized, probably because of compensating for my pain.
Take my hip flexors, for example. Please, take them and give me new ones! I should have known something was up last year at the ice dance seminar with Paul and Sharon, where we were asked to stand on one leg and extend the other in front of us at hip level with skates on, and hold it … and hold it … and hold it. I could not do this! It hurt my hip so much that I could only hold it for about 3 seconds vs. the 45 seconds or so they wanted us to hold it. Isolating those muscles I was subconsciously compensating for was impossible.
At the time I was embarrassed and just thought, OMG, I am so out of shape. But I wasn’t really out of shape. I was skating 6 days a week, 2 hours per day. My skating was strong and my stamina was good, but I, an ICE DANCER, could not extend my free leg in front of me while standing at the boards holding on!! People who appeared far more out of shape then I was could do the exercise, adding to my misery. At the time, I had no idea why this was the case. I was really embarrassed though and figured I was just a wimp.
Last night when I tried to do the leg lifts with 2 pound weights, working those same hip flexors, I could barely do 5 of them. FIVE! The recommendation was for 15. I will have to work up to that, starting perhaps with 1 pound. My skates must weigh at least 5 pounds. Don’t even get me started on the clam shell exercises. I could barely do them either. I believe those work the hip abductors, yet another set of lazy muscles.
So, aren’t these the same muscles I should have been using to skate all these years? Of course they are. What the heck have I been using all this time? I know I can extend my leg forward (in hip speak, this is actually flexion).
See picture, this is my bad hip flexed in the Starlight Waltz last year. (Note that my toe is turned in, where it naturally goes, which is absolutely hideous and which I usually conceal better than this, but still I am able to flex.) What muscles was I using to do all this, my mystery muscles? Or perhaps it’s all being handled by my big huge glutes. That would not shock me. OMG, I am all messed up.
I am shocked, SHOCKED to find out just how weak some of my muscles are, despite skating. I knew which muscles were overdeveloped, but wasn’t aware until now how many were underdeveloped and underutilized, probably because of compensating for my pain.
Take my hip flexors, for example. Please, take them and give me new ones! I should have known something was up last year at the ice dance seminar with Paul and Sharon, where we were asked to stand on one leg and extend the other in front of us at hip level with skates on, and hold it … and hold it … and hold it. I could not do this! It hurt my hip so much that I could only hold it for about 3 seconds vs. the 45 seconds or so they wanted us to hold it. Isolating those muscles I was subconsciously compensating for was impossible.
At the time I was embarrassed and just thought, OMG, I am so out of shape. But I wasn’t really out of shape. I was skating 6 days a week, 2 hours per day. My skating was strong and my stamina was good, but I, an ICE DANCER, could not extend my free leg in front of me while standing at the boards holding on!! People who appeared far more out of shape then I was could do the exercise, adding to my misery. At the time, I had no idea why this was the case. I was really embarrassed though and figured I was just a wimp.
Last night when I tried to do the leg lifts with 2 pound weights, working those same hip flexors, I could barely do 5 of them. FIVE! The recommendation was for 15. I will have to work up to that, starting perhaps with 1 pound. My skates must weigh at least 5 pounds. Don’t even get me started on the clam shell exercises. I could barely do them either. I believe those work the hip abductors, yet another set of lazy muscles.
So, aren’t these the same muscles I should have been using to skate all these years? Of course they are. What the heck have I been using all this time? I know I can extend my leg forward (in hip speak, this is actually flexion).
See picture, this is my bad hip flexed in the Starlight Waltz last year. (Note that my toe is turned in, where it naturally goes, which is absolutely hideous and which I usually conceal better than this, but still I am able to flex.) What muscles was I using to do all this, my mystery muscles? Or perhaps it’s all being handled by my big huge glutes. That would not shock me. OMG, I am all messed up.
Friday, October 31, 2008
PAO - my insurance company's view
"Management of individuals blah blah blah with this malady blah blah blah includes: modification of activities to reduce excessive motion and burden on the hip, the use of non-steroidal anti-inflammatory drugs, and discontinuation of activities associated with the painful hip movement."
Their answer = stop skating and that will solve the problem. Therefore such surgery is "not necessary."
Of course, if I stop exercising I will gain 50 pounds (I like to eat) which will open the way to heart disease, high blood pressure, knee pain, and diabetes, and then the fuckers will get to pay for my treatment for those things.
The surgeon's PA is trying to negotiate with the insurance company through their contract agreement and should have an answer by June of 2009, which is why my surgery is penciled in for July of 2009. They asked me not to interfere unless that does not work and I will honor that. After that, I will be getting my attorney involved. Good thing I have one in the family.
Terri
Their answer = stop skating and that will solve the problem. Therefore such surgery is "not necessary."
Of course, if I stop exercising I will gain 50 pounds (I like to eat) which will open the way to heart disease, high blood pressure, knee pain, and diabetes, and then the fuckers will get to pay for my treatment for those things.
The surgeon's PA is trying to negotiate with the insurance company through their contract agreement and should have an answer by June of 2009, which is why my surgery is penciled in for July of 2009. They asked me not to interfere unless that does not work and I will honor that. After that, I will be getting my attorney involved. Good thing I have one in the family.
Terri
Thursday, October 30, 2008
PAO
I finally got in to see the specialist today, after a 3 month wait. He specializes in people with my deformity, acetabular dysplasia, and he does a lot of pelvic reconstruction from trauma. He is very well regarded.
He told me that I was a good candidate for periacetabular osteotomy (PAO), and that a hip replacement or resurfacing would not work well because my hip sockets are so shallow. An artificial hip would probably fail fairly soon since there would be poor structure to hold it in place.
They took more x-rays and also did a CT scan to determine whether my legs were the same length and how much my femurs were misshapen. At the end of the day (and, with 4 hours of drive time, we are talking ALL DAY), it turns out that I have multiple problems. Very severe dysplasia, meaning very shallow hip sockets. Not a mild case. This had not been evident from the first films. I have stage 1 arthritis in both hips which, once pain is present, usually quickly degrades to stages 2, 3, and 4. Also, my femurs turn inward ("anteversion"), which I knew, but mine do so in the extreme, meaning my femurs are actually twisted. So that entails another surgery, where they break the femur and insert a plate. The PAO means they cut my pelvis up and reposition it, inserting screws. Some day I'll have a fully metallic pelvis - TSA will love me.
The upside is decrease in pain (although I may still have some residual pain), a more stable hip and leg structure, a slowdown or stop to the arthritis, and potentially no need for future hip replacement. If I do need future hip replacement, my bone structure will be much more amenable, meaning less likely to fail, after PAO.
Downside is that I may have less range of motion, although the femur revision may give me some more turnout. Normal turnout is 30 degrees, and I have less than 5 degrees - "essentially zero" as the doctor put it. I do have excellent "turn in," which is ever so ugly in skating. All of this means it didn't matter how many plies I did, I would never ever ever ever ever ever ever be able to do an Ina Bauer. The rhumba choctaw? Impossible for someone built like me (yet I do it ... my way). All the coaches and ballet teachers who said I just wasn't trying hard enough ... well, you know the gesture. I'm too emotionally drained to get upset about it again.
Another downside is that I will be in the hospital for 5 - 7 days, non-weight bearing for 8 weeks post surgery, and unable to skate for 6 months, at which time they will do the other hip! So this is really 4 surgeries and 2 hospitalizations and a year off the ice in total. The thought of getting my strength, stamina, flexibility, balance and skill back in my late 40's after going through something like that boggles my mind right now. I know it's possible, but will I just give up and take up golf? It's entirely possible.
Finally, my insurance doesn't pay for this. The total cost PER SURGERY is roughly $150,000. That's right, them's a lot of zeroes. And then multiply that times two. And oh yeah, will the insurance company pay for the special hospital bed I need at my home for a month, and the physical therapy, when they don't even cover the surgery? I'm thinking not so much. The doctor's billing assistant said they are working to get this covered and if I wait until next summer (which I have to do anyway), they may have made progress.
I could have raided my 401(k) or my home equity at one point, but in this economy that's just not an option. How to pay for it is a big question, but I have time to ponder that as they can't even schedule me until next summer. I am tentatively penciled in for July, pending the funding issue.
A year off the ice is an awful reality to face. I'm not ready for that. I am still improving as a skater! I am still competing! I am still testing international dances! I am not ready to quit and not ready to have a forced hiatus which I'll need to fight back from.
Hip replacement has a much shorter down time and is paid for by my insurance. But, if I trust what I heard today, it won't be very successful for me. It sounds like my options are limited.
Meanwhile I will continue skating until the pain gets too hard to bear. Right now it is pretty constant, but sleeping is the worst. Skating isn't as painful as sitting. Maybe I will get some crutches so I can keep the weight off it all the time except for that hour or so when I'm on the ice. No cross training as I can't risk it. But I vow to get through this competitive season - I've made a commitment to Tim which I think I can keep -- and then take the next step.
He told me that I was a good candidate for periacetabular osteotomy (PAO), and that a hip replacement or resurfacing would not work well because my hip sockets are so shallow. An artificial hip would probably fail fairly soon since there would be poor structure to hold it in place.
They took more x-rays and also did a CT scan to determine whether my legs were the same length and how much my femurs were misshapen. At the end of the day (and, with 4 hours of drive time, we are talking ALL DAY), it turns out that I have multiple problems. Very severe dysplasia, meaning very shallow hip sockets. Not a mild case. This had not been evident from the first films. I have stage 1 arthritis in both hips which, once pain is present, usually quickly degrades to stages 2, 3, and 4. Also, my femurs turn inward ("anteversion"), which I knew, but mine do so in the extreme, meaning my femurs are actually twisted. So that entails another surgery, where they break the femur and insert a plate. The PAO means they cut my pelvis up and reposition it, inserting screws. Some day I'll have a fully metallic pelvis - TSA will love me.
The upside is decrease in pain (although I may still have some residual pain), a more stable hip and leg structure, a slowdown or stop to the arthritis, and potentially no need for future hip replacement. If I do need future hip replacement, my bone structure will be much more amenable, meaning less likely to fail, after PAO.
Downside is that I may have less range of motion, although the femur revision may give me some more turnout. Normal turnout is 30 degrees, and I have less than 5 degrees - "essentially zero" as the doctor put it. I do have excellent "turn in," which is ever so ugly in skating. All of this means it didn't matter how many plies I did, I would never ever ever ever ever ever ever be able to do an Ina Bauer. The rhumba choctaw? Impossible for someone built like me (yet I do it ... my way). All the coaches and ballet teachers who said I just wasn't trying hard enough ... well, you know the gesture. I'm too emotionally drained to get upset about it again.
Another downside is that I will be in the hospital for 5 - 7 days, non-weight bearing for 8 weeks post surgery, and unable to skate for 6 months, at which time they will do the other hip! So this is really 4 surgeries and 2 hospitalizations and a year off the ice in total. The thought of getting my strength, stamina, flexibility, balance and skill back in my late 40's after going through something like that boggles my mind right now. I know it's possible, but will I just give up and take up golf? It's entirely possible.
Finally, my insurance doesn't pay for this. The total cost PER SURGERY is roughly $150,000. That's right, them's a lot of zeroes. And then multiply that times two. And oh yeah, will the insurance company pay for the special hospital bed I need at my home for a month, and the physical therapy, when they don't even cover the surgery? I'm thinking not so much. The doctor's billing assistant said they are working to get this covered and if I wait until next summer (which I have to do anyway), they may have made progress.
I could have raided my 401(k) or my home equity at one point, but in this economy that's just not an option. How to pay for it is a big question, but I have time to ponder that as they can't even schedule me until next summer. I am tentatively penciled in for July, pending the funding issue.
A year off the ice is an awful reality to face. I'm not ready for that. I am still improving as a skater! I am still competing! I am still testing international dances! I am not ready to quit and not ready to have a forced hiatus which I'll need to fight back from.
Hip replacement has a much shorter down time and is paid for by my insurance. But, if I trust what I heard today, it won't be very successful for me. It sounds like my options are limited.
Meanwhile I will continue skating until the pain gets too hard to bear. Right now it is pretty constant, but sleeping is the worst. Skating isn't as painful as sitting. Maybe I will get some crutches so I can keep the weight off it all the time except for that hour or so when I'm on the ice. No cross training as I can't risk it. But I vow to get through this competitive season - I've made a commitment to Tim which I think I can keep -- and then take the next step.
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