After 8 months of working on the issue of getting the wisdom teeth out and the jaw work done simultaneously by an out of network doctor who is highly regarded in his field, we threw up our hands in total frustration.
You may recall it started in December. Mel’s cartilage had migrated to the front of the jaw hinge. The specialist recommended arthocentesis and gave us an estimate for combining it with the wisdom teeth extraction. In December the matter would have been divided between Delta Dental for the teeth and Aetna HMO for the jaw. This is when we learned that Doc is not in the Aetna network. This required going to the primary care physician and getting a referral for the medical portion (even though the medical doc never had anything to do with it). After a couple of months and a zillion calls requiring intervention from the Aetna participator rep on the primary’s end we finally learned that it was up to me to search the list of participating specialists and find one in the network. After much more research I find only 1 in the entire metro area who does jaw work at all. He is 25.3 miles away in Chandler so I figure I am home free. I write in for the out of network approval. Well, it is denied ( the travel limit has somehow gone up from 25 miles to 30) which I learn after several more calls just two days before we leave on vacation.
I relent and make an appt with the network guy for the day after our return. This is time critical as college is starting in August, Mel is working and this is going to take some time. Well he does not want to treat the matter the same way, opting instead to do the extraction and try some splint therapy. And he was wrong on a number of things that Mel had just learned in anatomy class. Skeptical I call the regular dentist and he cautions that the original specialist knows what he is doing and if that were the efficacious route he would have recommended it himself.
So back to square one. I attempt to work out some kind of cash deal for the medical portion with the original specialist only to find that after January 1 Delta no longer covers wisdom teeth extractions if you have medical that will do it, the specialist’s rates have gone up and he forgot to include the estimate for the splint follow up on my document which is $1900. Now I would need to pay $4800 in advance and risk getting nothing reimbursed.
So now I am back on the insurance track again. I ask for a copy of the first denial, having never received it in the mail. Incredulous the Aetna phone person indicated I was out of luck-it was an electronic file and they could not make a copy. Now I have to get our HR department involved at work from whence the coverage emanates. Numerous conference calls later I finally get a hard copy of the letter faxed to me and now I know my appeal rights.
I appeal. I hear nothing until a couple of weeks later when I get a letter acknowledging receipt of my appeal. THE VERY NEXT DAY I get the denial. Now it seems that I have NO COVERAGE WHATSOEVER as TMJ is excluded under the policy under every circumstance. If only I had known that in first place. We consulted the policy’s fine print regarding the wisdom teeth but it never occurred to us that the jaw issue would not be covered.
We gave up. Mel got her teeth cleaned as the 6 months had elapsed between regular cleaing appointments. It was a bit challenging to hold her mouth open. But generally she is not in any immediate pain and her mouth limitations are bearable. Our new plan is to wait for open enrollment, change plans (I will never do the HMO thing again, EVER--something I had sworn off in the past but thought that Aetna would be a better deal than that old program, but, no, they are too busy spending $358 million buying a local insurance agency to pay for my piddling claims) and up the flexible spending account to cover what will be left. Of course that may be the whole thing as it will no doubt be considered a preexisting condition and declined even if we can find a jaw policy.
So I let it go.
Then the miracle. Seems Mel was jumping on a trampoline with her pal Ned and he bashed into her face (on accident). She said it hurt like hell for about 3 hours but ever since her jaw seems to be in perfect alignment. We are now rushing to get her to a regular oral surgeon (½ mile from our house I might add–not 25.3 miles away in Chandler) who will take both insurances and work it out from there. How is that for turning lemons into lemonade? I figure if I billed my time this whole thing would require a second mortgage on my house.
THIS SYSTEM IS INSANE!!!! We have got to get the insurance companies out of the way. There is no relationship with your doctor anymore and that is the key to maintaining proper health. By delaying and arguing and faxing and appealing we add huge costs to the system, the most major of which is the lack of efficiency (here we would have had two procedures, two anaesthetics, etc) not to mention the increased cost associated with treating the worsening condition while time passes. INSURANCE companies add nothing of value to the system. The value they add is to their bottom line. This takes all of the market place decisions and moves them to a secondary market. This dilutes the value of information necessary for making a sound economic decision in the market place. This is not capitalism-it is an aberration
I have noted before that the problem with capitalism and the environment is that it is impossible to put a market value on the air/water, etc.(this carbon trading thing is simply a bunch of hoo haw). Well we have the same problem in the health care industry. The cost of maneuvering the system, which is often borne by a coopted family member is never captured. Therefore the measurement is seriously distorted. If my time were quantified and added to the mix in this fiasco along the actual cost would probably boggle the mind and make it simply a bad way to go financially.
We need to get to the private health care account model as soon as possible (unless someone can come up with a better idea in the meanwhile). At least that would get the biggest impediment out of the way.
Now, I am really letting it go. I mean it this time.
Friday, August 3, 2007
Thursday, July 26, 2007
Looking at people in a different way
Check out this link to the Washington Post for some unbelievable images of Ron Mueck's sculptures.http://www.washingtonpost.com/wp-dyn/content/gallery/2005/12/29/GA2005122900888_index_frames.htm?startat=1
Saturday, July 7, 2007
Our Complete Vacation Photo Album link Euroland
http://picasaweb.google.com/Doogiekim.cox.net/Euroland2007
Tour the 20th Century With Billy Joel and Ye Li
This is visually stimulating.
http://home.uchicago.edu/~yli5/Flash/Fire.html
http://home.uchicago.edu/~yli5/Flash/Fire.html
Friday, July 6, 2007
Radio Killed the Newsprint Star
I happened to be in my car during Talk of the Nation on NPR on Thursday. Stephanie Roberts was guest hosting and interviewing an editorial board member from the Wall Street Journal about the Libby commutation. She mentioned that they had a hard time finding any newspaper’s editorials supportive of the move. I remember thinking to myself, “well I know one” as Doug’s quick hit that morning said just that.
At dinner that evening I mentioned this experience to my husband. Just then his eyes got really big and his face lost all color. “Oh, I get it now!” he said. Apparently an NPR producer had called him looking for the writer of the editorial to appear on TOTN. Well, Kathleen Ingley had written the editorial (which was not supportive) and Doug-- not appreciating the background --just referred the call to her; and of course they did not opt to put her on the air.
Only when I told of my cyber-experience in the car did he realize that yes, the producer was looking for him. But for the nuance of the Quick Hit vs. the Editorial, I could have been listening to my husband instead of that inarticulate WSJ dude.
Who knew?
At dinner that evening I mentioned this experience to my husband. Just then his eyes got really big and his face lost all color. “Oh, I get it now!” he said. Apparently an NPR producer had called him looking for the writer of the editorial to appear on TOTN. Well, Kathleen Ingley had written the editorial (which was not supportive) and Doug-- not appreciating the background --just referred the call to her; and of course they did not opt to put her on the air.
Only when I told of my cyber-experience in the car did he realize that yes, the producer was looking for him. But for the nuance of the Quick Hit vs. the Editorial, I could have been listening to my husband instead of that inarticulate WSJ dude.
Who knew?
How We Spent Our Summer Vacation
Byline:
Doug MacEachern, The Arizona Republic
VISITING EUROPE THE GIRL SCOUT WAY
It was not a highbrow tour of the old countries.
In Salzburg, Austria, we visited a castle where sprays of water gushed from the antlers of mounted heads of deer in a garden. Not -- how do you say? -- the stuff of resplendent Old World culture.
In Munich and Amsterdam, we sought out Mike's Bike Tours, as perfect an antidote to pretentious refinement as you can find in Europe.
If you wish to balance your parade of cathedrals and art museums with an American slacker's view of the continent, I highly recommend Mike's guided tours. Our leader, a young Hawaiian named Frankie, was amazingly versed regarding the Chinese Tower outdoor beer hall in the English Gardens of Munich. They serve lots and lots of beer there, you know.
And so it was throughout our group's little "sampler" tour of Europe. We did some theater in London. But, well, it was Monty Python's Spamalot. Not exactly A Midsummer Night's Dream in Regent's Park but a genuine laff-riot, nonetheless.
Which is not to say that our 16 days in seven European and British cities acked cultural or educational purpose. We toured the Louvre. Some of us did the "Da Vinci Code" tour of the Louvre (what is "kitsch" in Latin, I wonder?). But it's not like we wasted time in Paris hanging around the cafes of Montparnasse eating bad cheese.
Oh ... wait. We did that, too.
Left to my own devices, I might have sought out a bit more Shakespeare, a few more cathedrals and a lot fewer cities.
But this trip was not of my own device. It was a tour structured,organized and arranged by a troop of Girl Scouts, each of whom paid her own way for this tour de force across the world's most expensive continent.
Most of us know about what good things the Boy Scouts do for boys. Self-reliance. Character-building. Knot-tying. A lot of wonderful things. Few boys leave the Scouts lacking memories of camp-outs, canoe trips and adventurous forced marches through the woods.
For girls, though, Scouting is a different experience. Most girls who get into Scouting tend to drift away right about the age that their male counterparts are reaching their Scouting stride. There are girls who stick with it. There are girls who stay in Scouting through high school, often earning their Gold Award. But the very fact that you have to explain to most people what a Gold Award is -- it's the Girl Scout equivalent of Eagle Scout -- tells you all you need to know about the prevalence of older teens in the Girl Scouts. There just aren't many.
In our group of 16, there were four of them, as well as several parents of Scouts (including me), a few friends and neighbors. But it was the girls for whom the trip was organized, the last remaining members of a "travel troop" of Girl Scouts whose primary focus (besides, of course, doing good deeds) is organizing trips to Europe.
Under the aegis of troop leaders Stevi Shearer and Suzanne Gallas, my daughter's troop has traveled to Europe three times. In three-year sequences, they would conduct all manner of fundraising events and, of
course, sell countless boxes of Girl Scout cookies. Then, they used the proceeds for the big trip.
With all due respect to the boys, the diligence, determination and long-range true grit that it takes to accomplish such a feat puts even the best-ever Boy Scout jamboree into some perspective.
In a perfect world, such an enormous, years-long undertaking would seem amazing. In a world besotted of the values of instant gratification and thick with Paris Hilton role models, it is practically beyond
comprehension.
What kept the girls going was a goal -- a tantalizing, reachable goal that they knew would end with bike trips through Amsterdam and tours of the Louvre if only they stuck with it and worked hard.
And, except for the odd nudge from parents and the indomitable Stevi Shearer, they did it on their own.
As our Euro-slacker tour-guide Frankie might say, "How cool is that?"
Doug MacEachern, The Arizona Republic
VISITING EUROPE THE GIRL SCOUT WAY
It was not a highbrow tour of the old countries.
In Salzburg, Austria, we visited a castle where sprays of water gushed from the antlers of mounted heads of deer in a garden. Not -- how do you say? -- the stuff of resplendent Old World culture.
In Munich and Amsterdam, we sought out Mike's Bike Tours, as perfect an antidote to pretentious refinement as you can find in Europe.
If you wish to balance your parade of cathedrals and art museums with an American slacker's view of the continent, I highly recommend Mike's guided tours. Our leader, a young Hawaiian named Frankie, was amazingly versed regarding the Chinese Tower outdoor beer hall in the English Gardens of Munich. They serve lots and lots of beer there, you know.
And so it was throughout our group's little "sampler" tour of Europe. We did some theater in London. But, well, it was Monty Python's Spamalot. Not exactly A Midsummer Night's Dream in Regent's Park but a genuine laff-riot, nonetheless.
Which is not to say that our 16 days in seven European and British cities acked cultural or educational purpose. We toured the Louvre. Some of us did the "Da Vinci Code" tour of the Louvre (what is "kitsch" in Latin, I wonder?). But it's not like we wasted time in Paris hanging around the cafes of Montparnasse eating bad cheese.
Oh ... wait. We did that, too.
Left to my own devices, I might have sought out a bit more Shakespeare, a few more cathedrals and a lot fewer cities.
But this trip was not of my own device. It was a tour structured,organized and arranged by a troop of Girl Scouts, each of whom paid her own way for this tour de force across the world's most expensive continent.
Most of us know about what good things the Boy Scouts do for boys. Self-reliance. Character-building. Knot-tying. A lot of wonderful things. Few boys leave the Scouts lacking memories of camp-outs, canoe trips and adventurous forced marches through the woods.
For girls, though, Scouting is a different experience. Most girls who get into Scouting tend to drift away right about the age that their male counterparts are reaching their Scouting stride. There are girls who stick with it. There are girls who stay in Scouting through high school, often earning their Gold Award. But the very fact that you have to explain to most people what a Gold Award is -- it's the Girl Scout equivalent of Eagle Scout -- tells you all you need to know about the prevalence of older teens in the Girl Scouts. There just aren't many.
In our group of 16, there were four of them, as well as several parents of Scouts (including me), a few friends and neighbors. But it was the girls for whom the trip was organized, the last remaining members of a "travel troop" of Girl Scouts whose primary focus (besides, of course, doing good deeds) is organizing trips to Europe.
Under the aegis of troop leaders Stevi Shearer and Suzanne Gallas, my daughter's troop has traveled to Europe three times. In three-year sequences, they would conduct all manner of fundraising events and, of
course, sell countless boxes of Girl Scout cookies. Then, they used the proceeds for the big trip.
With all due respect to the boys, the diligence, determination and long-range true grit that it takes to accomplish such a feat puts even the best-ever Boy Scout jamboree into some perspective.
In a perfect world, such an enormous, years-long undertaking would seem amazing. In a world besotted of the values of instant gratification and thick with Paris Hilton role models, it is practically beyond
comprehension.
What kept the girls going was a goal -- a tantalizing, reachable goal that they knew would end with bike trips through Amsterdam and tours of the Louvre if only they stuck with it and worked hard.
And, except for the odd nudge from parents and the indomitable Stevi Shearer, they did it on their own.
As our Euro-slacker tour-guide Frankie might say, "How cool is that?"
It's All Sicko
Michael Moore is catching it for his latest opinumentary. Well, if his point is to make us all aware of the mess our medical system is in he is preaching to the choir. From the fallout it doesn't sound like he does a very good job of proposing a solution. But that seems to be the raison d'etre these days.
In this blog I have previously whined about the hassle with getting Melanie's dental/medical problems addressed. The medical system is bad enough--couple it with the dental and you have a Rube Goldberg machine.
After a month I have finally, and with the intervention of HR gotten the written denial to go out of network to my surgeon of choice. Aetna initially told me they mailed it to me once and could not print out another. That proved to be false.
The problem I now have is that we went ahead and took her to the only other jaw person on Aetna's list. Luckily he also took our dental plan. Dr. Shah is 25 miles away in Chandler (so much for global warming)and he decided we should try a splint first and scheduled her for the dental surgery.
This is nuts. I could get the dental surgery over here on the corner-I sure don't need to drive to Chandler. Further even I know a splint is not going to move the cartilidge back in place and even if it did it would not happen before Mel leaves for school. (We have been trying to schedule this for 8 months now and time is running out.) And when it does not work that necessitates another surgery with the concomitant anasthesia, cost and time out of pocket. Plus the guy said several things that were not quite right according to the recent student of anatomy.
So now we have to appeal.
Meanwhile, my mother was given a number of prescriptions she didn't even need and it seems like the surgeon forgot to put on a stoma when she had her perforation surgery. The surgeon's office refuses non-surgery related calls so she had to go back to her regular doctor to get him to call all these boobs.
It is all sicko, no?
We need to figure something out!!!!
In this blog I have previously whined about the hassle with getting Melanie's dental/medical problems addressed. The medical system is bad enough--couple it with the dental and you have a Rube Goldberg machine.
After a month I have finally, and with the intervention of HR gotten the written denial to go out of network to my surgeon of choice. Aetna initially told me they mailed it to me once and could not print out another. That proved to be false.
The problem I now have is that we went ahead and took her to the only other jaw person on Aetna's list. Luckily he also took our dental plan. Dr. Shah is 25 miles away in Chandler (so much for global warming)and he decided we should try a splint first and scheduled her for the dental surgery.
This is nuts. I could get the dental surgery over here on the corner-I sure don't need to drive to Chandler. Further even I know a splint is not going to move the cartilidge back in place and even if it did it would not happen before Mel leaves for school. (We have been trying to schedule this for 8 months now and time is running out.) And when it does not work that necessitates another surgery with the concomitant anasthesia, cost and time out of pocket. Plus the guy said several things that were not quite right according to the recent student of anatomy.
So now we have to appeal.
Meanwhile, my mother was given a number of prescriptions she didn't even need and it seems like the surgeon forgot to put on a stoma when she had her perforation surgery. The surgeon's office refuses non-surgery related calls so she had to go back to her regular doctor to get him to call all these boobs.
It is all sicko, no?
We need to figure something out!!!!
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