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Old 12-22-2008, 10:14 AM   #1
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More health insurance problems

I'm ranting to anyone who will listen today. I injured my shoulder two and a half months ago. Got misdiagnosed with a Grade 2 shoulder separation. It turns out that it is a Grade 5 separation. It isn't healing right, and the collarbone and shoulder blade aren't really attached.

So I finally saw a Good orthopaedic surgeon this past Friday. He took more X-Rays, which showed the huge amount of separation (which is obvious from just looking at my shoulder). I need surgery. Well, I was hoping to schedule surgery today. But it turns out that the only hospital he's affiliated with (which is a large hospital in our area) is not covered under my insurance. Out-of-network would mean I'm on the hook for 20% of the costs, once I meet my HSA deductible (of 5,700), and an additional 1,000 out-of-network deductible. 20% might well be pushing $10,000 -- hard (if not impossible) to get a straight answer on how much.

So now it looks like I have to find a different shoulder specialist to reconstruct my shoulder (take off part of my collarbone, pin things around, and replace ligaments with cadaver ligaments). Major surgery, I'm looking at 3 months in sling, so I wanted to get it out of the way as soon as I could.

Anyhow, I've gone through a whole bevy of emotions since I got the diagnosis. Right now I'm working on anger -- the insurance I originally bought included the local hospital, but they changed the network a year or two back and I (idiotically) never checked hospital affiliation again.

Time to up that estimate for health care costs when I'm retired...
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Old 12-22-2008, 12:07 PM   #2
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Sorry to hear about that separated shoulder!

I'll jump on the bandwagon and reiterate that's it's extemely important to keep tabs on the so-called "network" for your particular insurance provider. Not only from the standpoint of the insurance provider changing network membership, but also in terms of your doc or hosptital dropping out of the network and not telling you.

In my case, our family doc restructured his practice dropping a few partners and adding some new ones and renaming the practice. When I got my latest EOB, I found out he and his new practice are not in my insurance providers network and my last office visit charge was applied to the "out of network" deductible resulting in no payment.

After calling doc's business office and talking them into reducing the charge by 80% (what it would have been had they not dropped out of my insurance provider's network), I started to look for a new doc in the network. A few days later, I get a letter from the MegaCorp which supplies my retiree coverage stating that they are changing insurance providers and effective 1-1-2009 we're moving from insurer A to insurer B. I look up doc and his new practice with insurer B...... There he is! So, long story short, no need to find a new doc. Just a need to keep track of who is insuring you and what their network is......

I'm convinced this type of provider/insurer roulette will be more and more common going forward.

Edit: Perhaps your surgeon can refer you (and transfer your test results, records, diagnosis, etc.) to a trusted associate who is affiliated with a hospital in your insurer's network? And btw, if it were me and it turned out I really wanted the current surgeon to do the work, I'd pay the $10k.

Good luck with your outcome!
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Old 12-23-2008, 10:45 AM   #3
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Kronk,

Sorry to hear about the complications with your shoulder and insurance company. Keeping track of who is in and out of network is a continual struggle and not something one usually pays much attention to except when a doctor/specialist is needed.

I would echo the advice given by youbet on asking for a referal, and if I believed the surgeon you have is THE guy for the situation, I would pay the money.
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Old 12-23-2008, 11:17 AM   #4
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Ouch, that hurts more ways then one. I'd go with the advice of referral to in network by the diagnosing surgeon.

This would put some cramp in delivering hooks and reverse punches etc. but try and keep the rest of your body in shape.
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Old 12-23-2008, 11:19 AM   #5
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I'm ranting to anyone who will listen today. I injured my shoulder two and a half months ago. Got misdiagnosed with a Grade 2 shoulder separation. It turns out that it is a Grade 5 separation. It isn't healing right, and the collarbone and shoulder blade aren't really attached.
How did this happen?
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Old 12-23-2008, 11:47 AM   #6
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I would echo the advice given by youbet on asking for a referal, and if I believed the surgeon you have is THE guy for the situation, I would pay the money.
There are enough good doctors in this area that he's not the only one I'd feel comfotable going with.

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Ouch, that hurts more ways then one. I'd go with the advice of referral to in network by the diagnosing surgeon.

This would put some cramp in delivering hooks and reverse punches etc. but try and keep the rest of your body in shape.
I'm hoping for a callback from the diagnosing surgeon today; we'll see if that happens. I did get another name from one of my TKD students (who is the head of the E.R. department at the hospital that isn't covered), and since he was the one who referred me to the original orthopod, hopefully that'll work out. I'm hoping the diagnosing surgeon confirms that this guy is also good.

Fitness will definitely be an issue. I'm planning on continuing to teach TKD while in a sling, but I'll be giving up Brazilian Jiu Jitsu for at least 5 months, maybe longer. Hapkido will probably be too frustrating to spend much time there. I might work on some single-stick/knife Pikiti Tirsia Kali, but that isn't particularly strenuous. Looks like a lot of stationary bike, squats, and lunges.

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How did this happen?
Well, uh... here's where I'm embarrassed. I was demonstrating something I pulled from Jiu Jitsu to a small Hapkido class. One of those "we're not going to do this, but isn't this cool" things. I set my uke (partner) up incorrectly, went into the move and ended up landing on my shoulder from several feet up with my own nearly 200 pounds and some of my partner's weight as well.

I made a whole bunch of poor decisions right there. Sometimes it is good that stupidity is immediately and severely punished, but in this case I'm not thrilled with the severity.
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Old 12-23-2008, 12:51 PM   #7
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Hey Kronk, I used to work in outpt orthopedics when I lived in the the philly area. I'm a little rusty on names, but I know a lot of PT's in the area - if you need a list of the good shoulder docs I'm sure I can come up with a few names for you. The first one that pops into my mind is Dr. Gerald Williams of the Rothman Insitute: Rothman Institute Orthopaedics : View All

Sorry to hear about your shoulder being worse than you thought!!
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Old 12-23-2008, 01:15 PM   #8
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simple girl, thanks for the name. Unfortunately, he's not in my network (nor is Rothman).

Diagnosing surgeon still hasn't called, grumble grumble.
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Old 12-23-2008, 07:02 PM   #9
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simple girl, thanks for the name. Unfortunately, he's not in my network (nor is Rothman).

Diagnosing surgeon still hasn't called, grumble grumble.

Bummer! Don't you hate it that you have to play by those rules?

If you don't hear back from the surgeon, feel free to PM me with your network list of MD's. I'll see if any look familiar.
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Old 12-23-2008, 09:28 PM   #10
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Well, uh... here's where I'm embarrassed.
I was demonstrating something I pulled from Jiu Jitsu to a small Hapkido class. One of those "we're not going to do this, but isn't this cool" things. I set my uke (partner) up incorrectly, went into the move and ended up landing on my shoulder from several feet up with my own nearly 200 pounds and some of my partner's weight as well.

I made a whole bunch of poor decisions right there. Sometimes it is good that stupidity is immediately and severely punished, but in this case I'm not thrilled with the severity.
Ah a learning moment. And a reminder to self. I've done similar, fortunately without lasting injury.
Don't do a move on uke until uke has performed a good attack, (need uke's momentum to manipulate his mass). If attack is poor or uke is planted tory has no need for a defense. As my teacher was fond of saying there is no need to defend against a non-attack.
He often walked away when i made a half a$$ed attack.

By the way I do hope you get good doctoring and be able to resume the art.
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Old 12-24-2008, 07:35 AM   #11
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Definite agreement about those non-attacks. Drives me nuts. One of the biggest complements I've gotten was when a 7th dan Hapkidoist told me that my punches always made him a bit nervous (and not because of lack of control).

I'm sure this will work out sooner or later. I went to what might have been my last Brazilian Jiu Jitsu class in a while. It was an open mat class, and I got a lot of grappling in.
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Old 12-30-2008, 12:47 PM   #12
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It can always get worse.

Need an X-Ray on my foot. I smacked it yesterday, and the stupid thing is extraordinarily painful to walk on.

My frequency of injuries is increasing. Must be getting old.
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Old 12-30-2008, 12:56 PM   #13
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It can always get worse.

Need an X-Ray on my foot. I smacked it yesterday, and the stupid thing is extraordinarily painful to walk on.

My frequency of injuries is increasing. Must be getting old.
I feel the same way,

At 29 I needed foot surgery, at 35 lower back surgery, at 41 knee surgery and at 49 shoulder surgery (both of them).

However, I don't intend to give up exercising, just listen to my body and modify as necessary. (e.g. I gave up playing soccer as I could not control the sudden impact aspect and became a referee instead).
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Old 12-30-2008, 02:09 PM   #14
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Doggone it Kronk. You gonna be the the meanest one legged, one handed fighter east of the Rockies.

Now start working on the martial artists' secret weapon: guile!
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Old 12-30-2008, 04:43 PM   #15
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Fractured my 2nd toe. I've got a shoe thing with a rigid bottom, and they buddy-taped the second and third toes together. Didn't think it felt like a toe, I thought it felt more like my foot.

Walking not good for at least a week. 4-6 weeks to really heal, apparently. Hopefully within that time frame I'll get my shoulder surgery.

I'm 34 and falling apart... 'Course, that was a pretty good smack. I was working across from another black belt (just warming up), and he came down with a front rising kick as I was going up. His heel whacked my foot, and the skin between my first and second toes split enough to bleed a bit. There's no excuse for us not having the right distance for the drill. I told my instructor that any more of these preventable training injuries and he'd have to take my rank away. I was mostly joking, but seriously, a 2nd dan shouldn't do that. At least I was the one who got hurt.
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Old 12-30-2008, 07:19 PM   #16
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Ok. You have beat yourself enough.

I'm 61, fortunately only had one serious injury all these year of Ju Jutsu. That small shoulder injury happened when I forgot the old admonition -- white belts are deadly. That was about 20 years ago, the shoulder still makes a good barometer.

Having shown shiho nage to an eager white belt, gave him my arm for practice, he promptly with full power proceeded to apply it, only the counter prevented a dislocation.

Sill hoping for your full recovery. Travel in peace.
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Old 01-18-2009, 08:23 PM   #17
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Surgery tomorrow morning. I'll try to post once I get back in a couple of days so you know that I didn't croak on the operating table.

The surgery is happening at a hospital 30 miles from home, rather than the one 2 miles from home because of my insurance. And hopefully there aren't any unpleasant surprises once the bills start rolling in.

I thought about posting a picture of my shoulders, but then you'd see my unsightly body hair.
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Old 01-18-2009, 08:27 PM   #18
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Good luck Kronk. Hope you get cut good.
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Old 01-18-2009, 08:38 PM   #19
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Good luck Kronk. Hope you get cut good.
Kronk, you don't like like you need a haircut. All the best with the shoulder. Hope you can type up a report for us soon.
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Old 01-18-2009, 09:49 PM   #20
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I thought about posting a picture of my shoulders, but then you'd see my unsightly body hair.
Good decision to hold back on the picture

Good luck with the surgery
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