A Pitcher's healthcare hypothetical

The subscriber and parent should call the insurance company immediately and ask what steps need to be done by them for an immediate medical review. I would also recommend contacting the powers that be that regulate the plan on the employer/government end. Taking no for an answer is the only thing that isn't an option.

The insurance company is your government. Fully funded, sponsored, and managed by government agencies. Where is your negotiating leverage in this case? Do you expect the government to review this case and rule against itself and its mandated coverage policies? Have you ever fought city hall and won?

I'm sorry, I think I misunderstood where you were going with this. There are many government entities across our nation that are "self funded" insurance programs and I thought that is what you were referring to.

We actually have a HSBBW member who had what I believe was a torn labrum if I remember correctly and he lived in Canada. Because of the complications of a long delayed MRI, he lost his scholarship, etc. He also shared personal stories of his father who suffers from End Stage Renal Disease. I am amazed at the differences in the health care systems and what a person can obtain. There are no easy answers when it comes to the healthcare delimma and how it would touch the lives of athletes is really a small question in the scheme of things.

The goverment/insurance company doesn't have any appeals process? If so, maybe you can get your orthopedist to petition that UCL reconstruction surgery is medically necessary to live a normal life.

While my HMO paid for my son's TJS they were stingy with the PT. We went through the appeals process which required letters from the surgeon and PT that further treatment was required. Although the process took a few weeks we got the additional PT he required approved.

What about the insurance from the team he was playing on at the time he was injured? My son was injured during the HS season and their insurance has paid for everything mine didn't cover including deductibles and copays.

If all else fails and your son is truly a prospect it might be worth it to pay for it your self.

Given that this is a real case and not conjecture, the answer is usually based on the question as asked, and the diagnosing doctor should have been aware of the system and how to present the case as medically necessary. Example, although not at all in the same league: I recently had a gap between teeth filled in, which was primarily for cosmetic purposes. My dentist "rang it up" as a filling (stretching the definition) so my insurance would pay a portion.

Perhaps a second opinion from a more sympathetic doctor would gain a better result. Unfortunately, the response is true; the procedure is not medically necessary, and the pitcher is a hs student, not yet a professional, so his livelihood does not depend on his arm.

I would imagine this has happened before. As he is probably talking to some colleges, perhaps one of the coaches there might have experience with the situation.

Alot has to do with how your doctor writes the diagnosis---sometimes you have to almost dictate it to him and them you proof read it

In this hypothetical situation you could always just pay for the procedure. If you have the money and think it's a worthwhile investment.

If the question is truly hypothetical then I assume that the purpose of the question is to bring attention to one of the possible ramifications of nationalized health care.

If the situation were real then the approach would be to fight the insurer and force them to accept the medical necessity for a baseball player. There's plenty of precedent for that.

Our situation was similar...but...different. However the same approach could be taken.

The surgery was approved by the insurance company, however, The operation had to be done within the providers network. In our case, with Madison being a "black hole" in regard to baseball, the TJ procedure would have been done by a doc who had only read the procedure while sitting on the bathroom throne. I considered that unacceptable, they said there was no reason the kid could not lead a normal life regardless of what orthopedic surgeon did it. I then took the offensive.

At the time Ryan was a draft eligible Junior in college and was on the radar of most teams, most of whom he had worked out for. With the help of his advisor, I emailed 5 MLB GM's who had shown direct interest, explained the situation, and asked that they write a letter explaining that Ryan was a pro prospect and that his surgery should be performed by a qualified professional. All five understood my angle and wrote personal letters recommendation. I took the letters and baseball related TJ statistics to the HMO review board and told them that while I was an anti-litigation, I was holding the proof that their decision was potentially "career threatening" and that while the chance of a lucrative contract were slim, I was prepared to take them as far as possible if their surgical alternative failed.

They took the carrot, I made the arrangments, and 2 weeks later Ryan was on Dr Andrews table in Birmingham AL and the HMO covered 100%.

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If the question is political then ignore this post...

On the oft chance that the question is or real and soemone wants help...and I suspect that there are some out there...

...then I'll hijack this thread (out of the political realm) and talk about option for a young player with TJ...

I am different than most. Money is a huge issue with us but I will not let it take take my son's dreams. I'd fight as far as I could...then as a final option I'd pay for the surgery. In my world simply can't put a price on my son's dreams and if he honestly has that much talent then it's a price I pay, a risk I take.

Here is another obscure option...

There are DI schools, who find it very hard to recruit players of that ability and have a track record of signing high end players with late HS injuries snd who as a result have been dropped from consderation by high end DI programs and rehabilitating them and holding a roster spot...in return for a comittment. While I doubt that such schools would pay for the surgery they might do/fund the full rehab.

Here is one case, high end DI LHP, mid 90's...TJ late in his career...as a result was dropped by all the elite schools...signed with a mid DI school, they rehabbed him for a year (I was told $35K worth) and got him back to health and velocity...the bad news for them was that he went back on his comittment...trasnferred to an elite DI...was an all-american...drafted, spent a year in the minors, and now is in the majors. The point being that if I were totally out of options I'd explore this one.

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I think dbg was asking more of a political direction regarding healthcare.... but

If not, then my original answer and the way Rz handled his son's case is EXACTLY what one should do. You ask for a medical review (immediate) and pursue all routes and make as much noise as you can. Also, your HR dept - don't leave out of the equation.

I was a nurse for an insurance company for years... the squeaky wheel gets the grease folks. If you're talking about a traditional HMO type of coverage.

"Have you ever fought city hall and won?"


I take it you meant this as a rhetorical question.

But for myself, there is an answer, and the answer is, "YES, many times."

My guess is the original post is a hypothetical based on future possibilities of nationalized healthcare. While the baseball scenario is a legitimate one, the first debate should be do we want to have a political debate on nationalized healthcare on a baseball board?

quote:

RJM quote:
the first debate should be do we want to have a political debate on nationalized healthcare on a baseball board?

I'd rather be poked with a stick in the eye, then we can talk health care .

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List to myself...

....Top Ten Topics NOT to be brought up on the HSBBW:


1. Rotational/linear Hitting

2. Religion

3. Bad High school coaches

4. Value/Stupidity of Weighted baseballs

5. Anyhting Political

6. Ice after pitching

7. Healthcare

8. "Jimmy" "Vinny"

9. Steroids

10. Karma


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Totally correct!!

quote:

Originally posted by observer44:
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List to myself...

....Top Ten Topics NOT to be brought up on the HSBBW:


1. Rotational/linear Hitting

2. Religion

3. Bad High school coaches

4. Value/Stupidity of Weighted baseballs

5. Anyhting Political

6. Ice after pitching

7. Healthcare

8. "Jimmy"

9. Steroids

10. Karma


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I think eliminating Jimmy is a bit harsh...Vinny maybe, but what's poor Jimmy done to make your list?

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Ya know CPLZ you're right...God knows the kid's taken enough abuse....

...Fixed the original...


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Under our national health care system we don't have these problems.