From: cochran@spam.rtp.dg.com (A. Jing Hippy)
Subject: Brace yourself
Date: Mon, 21 Dec 92 18:22:01 GMT
Organization: A Suffusion of Yellow

So I get some good news on the whole leg-break, slow recovery, crutch,
wheelchair miasma that I've been going through for the past 14 weeks.
The doctor says that I can be put into a leg brace which will allow me
more movement and easier access to things.  The brace is removable for
things like showers, bedtime, excercising the poor, stiff, atrophied 
limb, thus speeding healing and giving me a 6 to 8 week head start on
walking normally again.

The doctor removes the cast from my leg and sends me home for the
evening with instructions to be *very* careful.  A fall or a twist of
this leg with my weight on it could snap it again.  I'll get the brace
the next day.

Wrong. The orthopedist says that to adequately immobilize the joints on
either side of the break, I need a custom-fitted leg brace that will take
about a week to prepare.  So we go downtown, I get measured for a brace,
and then back to the doctor's office to have a cast put back on for the
week or so that it will take to get the brace.  That was two weeks ago.

Last Wednesday, I called the orthopedist to see how it was coming along. 
He tells me that he hasn't heard from the HMO and that he's not going to
make this *very* expensive piece of metal and leather sculpture until he
finds out that they'll pay for it.  I called the HMO.  2 days and a dozen
phone calls later, I find that my case is before the HMO's "Medical Review
Board" and that they have not arrived at a decision on it yet.

I call in my doctor, my orthopedist and my personnel folks here, and they
get something done.  Now the HMO's "Medical Review Board" has made a 
decision.  The decision that they've made is that they can't reach a 
decision, and my case must be forwarded to the "Medical Director".

The "Medical Director" makes a snap decision (several hours later).  A leg
brace is not a "medical necessity", and therefore they won't pay for it.

Scramble, scramble, phone, phone, yell, yell.  OOops, too late, it's after
4:30 and everyone has gone for the day on Friday afternoon.

Monday morning. Personnel person calls me with a phone number and name to
get something done.  HMO person tells me that they never received medical
records on me from Bermuda where the surgery was performed, nor have they
received anything from my doctor stating that the brace is medically
necessary.  Doctor's office says that all that stuff was faxed a week ago
and HMO should have it.  David give HMO number and name to doctor's office
and we'll see what happens.

Meanwhile, I called the orthopedist back and asked him to go ahead and start
on the brace.  I'll pay for it myself if I have to.

Peeve: My health care is ultimately in the hands of pencil-pushers at Blue
       Cross in Durham, NC.

Peeve: I may have to lay out big bucks for a custom-fitted leg brace.

!Peeve: The orthopedist is gonna knock $100 off the price of the brace if
        I pay for it myself.  He tells me that they usually don't discount
        insurance companies because there's no need to.

Peeve: The !peeve shows what a racket the health insurance industry is and
       why my paycheck is ravaged every two weeks with payments to an HMO.

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|Dave Cochran, Data General Corporation, RTP, NC   |
|cochran@dg-rtp.dg.com                             |
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|"Reality is nothing but a collective hunch."      |
|                                   --Lily Tomlin  |
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