Dr. Wolford (Texas) expects full payment before surgery

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#16 Post by **jul** » Sat Jun 13, 2009 10:58 am

Have you asked for an out of network exception someone else has mentioned. I would check your plan about the exception. Another thing that might be helpful is asking an in network oral surgeon to write a letter referring you to Dr. Wolford, stating that he/she is unable to perform the needed surgery and Dr. Wolford would be the appropriate surgeon. Have your sleep doctor do the same. Many people here have been on the insurance merry-go-round, myself included. I don't know if this helps but good luck.

#17 Post by **smile2006** » Sat Jun 13, 2009 4:39 pm

I'm sorry to ready your story and I hope you find a solution. The problem is that insurance companies don't respect how specialized this surgery really is and tend to underpay surgeons so therefore alot of surgeons opt not to accept many insurance companies when it comes to this type of surgery. I have BCBS for State Employees (a huge insurance group). I live in the capital of the state and no surgeon in the city accepted my insurance and like you, I found the price of an out of network surgeon unreasonable for upper/lower/genio. There were only 3 surgeons in the state that accepted my insurance (and the case had to be well documented as medical necessity). I lucked out and got a great surgeon who did a great job but I drove about 75 miles to get to him. When my insurance paid him for the surgery his office decided it was more cost effective for them to write the cost of my surgery off. They returned the insurance payment from BCBS and returned my out of pocket portion to me. Now for me this was great because the surgery ended up to virtually free but the reason it was is pitiful. Good Luck!

#18 Post by **ladyjenie** » Sat Jun 13, 2009 7:41 pm

jul, I have a letter from Aetna saying Dr. Wolford was approved in-network but the list they sent of what they're paying is at out-of-network rates. I am working thru my husband's HR dept. to see if they can politely force Aetna to pay @ 80% as their letter states. For $38,000 I will postpone the surgery for a few months while we duel. I guess Aetna has success in people paying the bill themselves and they're off the hook. I don't plan on doing that. I will write my state senator if I have to.
Smile2006, my intent is to hold Aetna to their letter they sent showing they will pay at 80% because of network deficiency. I feel I am holding the trump card but I have to play it right, don't I? Aetna referred me to an OS a few months back and he recommended I see Dr. Wolford because no doctor in Texas could do what Dr. Wolford does with orthognatic surgery. Aetna has that letter but still refuses to budge. Wolford is 100 miles from me but I'd be glad to drive there if only Aetna would step up to the plate and do what is right. I am glad I have all my friends here rooting for me. THNX!

#19 Post by **fromjersey** » Sun Jun 14, 2009 6:56 am

ladyjenie : sounds like you are holding on and not rushing into anything. How sad that Wolford gets called "notorious" for his outrageous fees, and beforehand! I don't think i would want such a person operating on me, regardless of his expertise.
Helen

#20 Post by **ladyjenie** » Sun Jun 14, 2009 10:33 am

fromjersey,
My husband is wanting me to find an OS in network because of the cost. I'm not opposed to that but I would have to travel several hundred miles and I'd have questions as to the OS's success rate. I don't want to be a statistic. Being disabled makes it nearly impossible to travel long distances and stay with the follow-ups. I assume Dr. Wolford "owns" the market for this area and uses it to his advantage, pure shame. That is just an opinion. But on the other hand having the disability issues makes me want to use Dr. Wolford so I won't have to go thru this twice. My ortho and the first OS I saw both recommended Dr. Wolford and didn't mention any other 'hopefuls'. I have asked on another post for recommendations to other OS's in the DAL area and haven't had any posts yet. I'm keeping my fingers crossed Aetna will have to pay more due to network deficiency.

#21 Post by **smile2006** » Sun Jun 14, 2009 11:41 am

If he is in-network than he has agreed to a contracted price for doing the surgery and he can't charge more. If he is really out-of-network and your insurance made a clerical error than that stinks for you but I would guess there is little your insurance company can do other than fix their mistake. It should be fairly easy to find out if he is "in" or "out" of network in your list of providers. Press on and good luck.

#22 Post by **ladyjenie** » Mon Jun 15, 2009 12:29 pm

Smile,
Dr. Wolford is out-of-network. Earlier, I was vague in what Aetna's letter said, sorry, my error there. Their letter read:
"Dr. Wolford will be allowed at the in-network benefit level that applies to your plan due to a network deficiency. Physicians, hospitals, and surgery centers are paid @ 80% of the in-network negotiated fee after you have met your deductible".
The key statement "negotiated fee" grabs you in the seat-of-the-pants. Dr. Wolford nor any other OS in Texas is in Aetna's network.
I spoke to Dr. Wolford's office today and his assistant told me they know of one other OS in Texas that does orthognatic surgery and he charges $500 less than Wolford and hasn't done but a limited # of surgies (scarry??), he is not a network provider either.
Aetna has done their homework on catastrophic surgeries but I know I wouldn't be going thru all this if I were having any other high-dollar surgery.
BTW, Dr. Wolford's office told me the money I owe ($38,000) has to be paid before the CAT scan for the customized implants can be ordered. OUCH!!! Now where can I dig up 38-grand??

#23 Post by **smile2006** » Mon Jun 15, 2009 1:07 pm

OK I see. Well that is a real bummer. My surgery was almost 3 years ago. I was considering a well respected surgeon who was closer to where I live but "out of network" his fees would have been about $16,000 for upper, lower and genio. That was more than I had on hand so I easily see how must feel. In my case, I was ended up very satisfied with my "in network" surgeon (he actually was a nice and caring guy and to this day when I look in the mirror I am thankful to him) so it turned out in the end. Hope your does too, let us know how the saga continues.

#24 Post by **ladyjenie** » Mon Jun 15, 2009 5:29 pm

Smile, I have been racking my brain today to see what shakes out and I've come to the conclusion that my next move is to find out is this an Aetna issue or a company issue (husband's employer) I'm fighting, then I'll know who to throw darts at. Meantime I am giving the companies' HR dept. time to discuss my issue with Aetna. The only thing left after that is a 2nd level appeal or hiring a lawyer to make a phone call to Aetna. The lawyer will interpret Aetna's terminology better than I. If I'm going to pay Dr. Wolford over $38,000 why not add a few more thous for a good lawyer.

#25 Post by **Braceschris** » Tue Jun 16, 2009 1:51 pm

I would find out who the insurance broker is for the company and ask for all the plans etc. Explain the problem to him/her and see what they might be able to do for you. The squeaky wheel gets the most as they say. I wonder what type of special CAT scan is required. I bet they would pay for that in a hart beat with no problem. Good Luck and let's know what goes on.

Chris

#26 Post by **ladyjenie** » Tue Jun 16, 2009 11:13 pm

Bracesc,
I'm not sure what you mean when you say "company insurance broker", is that a 3rd party that secures benefit pkgs. for the company? I would like to know more so I can put that question to the HR person.

I saw my orthodontist today and explained that I could not afford to pay this money out-of-pocket for Dr. Wolford. He referred me to an OS in Shreveport, LA (Dr. Ghali) who is reputable at TJR. And he's in my network!! That means he'd accept a negotiated price with Aetna and my secondary, Medicare would pay a portion of the 20% balance (they never pay it all). With Wolford I was responsible for filing my own bill with Medicare because his office wouldn't do it for me. They want no responsibility except to extend their hands flat side up -- cash.

On the CAT scan, it is needed in customizing to fit my jaw and must be taken a couple months before the surgery date. I also had a CAT before my consult with Dr. Wolford and he used it for the tracing of my facial structure. Yes, it was paid at 100% because the hospital was in-network.

Thanks for mentioning the insurance broker, I'll ask that question.
lady

#27 Post by **Braceschris** » Wed Jun 17, 2009 12:53 pm

Yes you are correct. It is just like when you go to your independent insurance agent and he gets you offers from 3-4 companies for you to look at before you purchase insurance. They should be able to put pressure on the insurance to do something. I really have never understood why it is so hard with dental work etc. I run into the same type of problem with worker's compensation insruance when a person has an injury to a tooth. They are able to handle all medical but when it come to dental everyone does not know what to do. Maybe you can get the Oral Surgerons to talk to each other and do what the one was going to do. It sounds like to me the one doctor just does not want to deal with all the insurance issues that goes with it. He would rather see you take care of it instead. Good luck with this part. ALso keep in mind you might be able to get money back on your taxes and if you have a flex medical spending account. Just go tot the IRS site and you can find more information on medical and how to take it off your taxes. Travel and hotels would also be covered in the ded.

Chris

#28 Post by **ladyjenie** » Wed Jun 17, 2009 3:18 pm

Hello everyone. I may have a solution to getting my surgery paid by my insurance. I spoke to my orthodontist yesterday about being unable to pay $38,000 to Dr.Wolford for TJR. He totally understood the hardship. He referred me to another OS that is just over the state line in Shreveport, LA, about the same distance as Dr. Wolford in Texas. My ortho called Dr. Ghali and spoke to him about my case (that I started with another doc). Now I have an appt. with Dr. Ghali for July 13th. Dr. Ghali is on the board of AMA for Oral & Max. Surgery and just returned from lecturing in China. I will feel better after I meet with him but jubilant that now both my insurances will pay. I also spoke to Dr. Wolford's office and told them I was changing courses and using another surgeon and she wished me good luck. Prayers work! Thanks! ladyjenie

#29 Post by **Braceschris** » Wed Jun 17, 2009 5:31 pm

Good to here that you found another doctor who is just as good as the other. Also I would suggest you go your first doctor and get all your records and take them to the new doctor to ensure that every thing gets there. Good luck.

Chris

#30 Post by **ladyjenie** » Thu Jun 18, 2009 12:06 pm

Braceschris, thanks for your concern. Yes, I will secure my records from Dr. Wolford's office. His office manager called me within 5 minutes of my making my appt. with the new OS. She had been contacted by my othodontist that I was changing doctors. My husband and I are nearing retirement age and the last thing we want to do is take $38,000 out of the pot. We pay dearly for our 2 insurances and frankly I want them to pay appropriately. The doctors that don't contract with insurances should notify patients in writing, up front, that they expect payment before services begin and dealings with insurance are their own responsibility. It cost me over $600 to find this out.