Need Orthagnathic Surgery- Need suggestions re: Price

[embervine]

Hi there- This is my first time posting the the website- I have read many posts and it has been very helpful so far. I am 25 y.o F and have known since I was 1 that orthognathic surgery was the only route to fixing the problem- my parents couldn't afford it, and it really wasn't physically bothering me at the time, so I just sort of pushed it out of my mind. However, the past couple years have been sort of rough, predictably, my bite has dramatically worsened with age, and I now have TMJ, sleep apnea, I wake up every night b/c my mouth is so dry b/c it won't close when I am sleeping, it hurts to eat and chew and even talk after a while. I am an office manager at a doctor's office, and have to talk ALL day, so this whole thing is just snowballing and driving me crazy. I have mandibular prognathism, open bite, crossbite, and an underdeveloped maxilla. I have been to the orthodontist, a couple actually, and the consensus is that I need a year of braces and then a saggital split osteotomy of the mandible and a Lefort 1 osteotomy of the maxilla. My maxilla also needs to be widened, they apparently use a bone graft from the hip or chin for this? Anyway, I though my insurance would cover this, since it is medically necessary and all; however, just found out a couple days ago and it is an excluded benefit, and all oral surgeons are out of network. The insurance costs $300 per month per person, BCBS, through my husbands work and I am livid. SO, I haven't gone to the oral surgeon yet, have an apt in Jan, but I have a couple questions for anyone out there who has experienced this before:
1. Has your insurance listed orthagnathic surgery as an excluded benefit and were you able to get it approved anyway- Maybe by working with work HR dept etc? Any tips for the precert process? Our plan excludes treatment of anything related to TMJ, so I was thinking of having the precert form submit stating that I have sleep apnea, breathing/speech/chewing difficulty and excluding TMJ from the diagnosis and seeing if that works?
2. If you have needed both upper and lower jaw surgery and had to pay cash, how much did you pay? Are you able to take out a small loan to help cover the cost of the surgery, if so, where do you get the loan from?
3. I saw on here that a couple of you have gone to Costa Rica to get this done-Specifically Dr. Oscar Reiche Fischel- If you have gone there for this type of surgery, or know someone who has, I would be so grateful if you could share your experiences with me- Given the cost of things, it might be the only realistic alternative at this point.

Thanks for participating in this message board, I don't know anyone who has had this done, and really appreciate being able to connect with people who have gone or are going through this.

[embervine]

Oops, I have known since I was 10 and not 1 as I stated in the last post there, that I needed the surgery...

[hduggan]

During the time when we were trying to get my son approved from surgery, we switched insurers 3 times (due to work stuff - not for this reason). The first three had it as an excluded procedure, and my oral surgeon felt it wasn't even worthwhile to talk to them about it. The last one, a blue cross provider out of Pennsylvania, did not have it excluded and my son ended up getting approved.

Before the approval, we were quoted a total price of around $18,000 for the full surgical procedure. To keep the cost down (and, yes, that's a low cost) my oral surgeon has his uninsured patients spend the night at a nursing unit instead of sending them to the hospital, and he does the surgery in a non-hospital surgery center (or maybe in his office).

The full price with hospitalization is probably three times this price.

[hduggan]

Oh, one other idea. I live near a teaching hospital, and that hospital offers orthodontic work at an insanely low price. I *think* it was something like $400 or $500 for the work-up, and then free after that. When we talked to them about orthodontic surgery, they claimed that their oral surgery department almost always managed to get insurance to cover it. I have no idea if that's true, but it might be worth approaching a teaching school and seeing what they suggest.

[chicago29]

The insurance game is tricky. The first thing I would do is find an oral surgeon in your area and consult with them. They will contact your insurance company to see how much of the procedure will be covered. Generally speaking, if it is out of network it will be 25 to 35% of the surgical costs. If it is in network, you only have to worry about your deductibles and/or co-insurance.

If your insurance company explicitly excludes orthognathic surgery, then there isn't much you can do. However, if it isn't excluded, leave it to your surgeon's office to figure it out. That's what they do and that's what you're paying them for. They know how to play the game. And yes, I say "game" because that is what it is. They have to use the right terms in order to get it covered under medical. Personally, I think it is insane that they have to jump through hoops like this, but many insurance companies view this as purely cosmetic and that's a shame. A bad occlusion is a medical condition just like anything else.

If this route doesn't work for you, your other two options are medical tourism (i.e., Costa Rica as you suggested) or a university teaching hospital. Both of these will be significantly lower cost. There are people on here that have done Costa Rica with Dr Reiche, and I believe overall that people are happy with that outcome. A university setting is what it is - You're going to have medical students in on the procedure, but obviously somebody experienced would be directing the show and would be involved. You will need to determine if this is something you can handle. I know people that have done the surgery in this setting and their outcomes have been great.

Just a rough idea of what all of this can cost with a private practice surgeon:

- Upper/Lower Surgical Fees: $12,000 is the cheapest I've heard - The most is over $50,000 if you go with one of the "rock star" surgeons. I'd say $20,000 to $25,000 is normal range. The fee is split more or less so if you only need one jaw done, you could figure half these amounts

- Hospital: Likely around at least $15,000 inclusive of the OR fee, drugs, equipment, etc. If you add other nights this will go up significantly. I was in hospital for 3 nights and my insurance company was billed upwards of $48,000. Now, this is what is BILLED. Your insurance will pay far less assuming you stay at a network hospital, and if you had to pay cash I'd try to agree to about 25% of the billed fee in advance of the procedures

- Anesthesia: Depends on how long the surgery is. An experienced private practice surgeon can do an upper/lower in 3 to 4 hours. A university setting can take 6 to 8 hours. Generally, it is around $1000.00 per hour you are under

My best advice is to stay strong and fight like hell, and be prepared for a lot of research, paperwork, etc. If you do this, you can probably get the insurance company to pay. Just don't think it is going to be easy...

Best of luck to you.

Regards
Chicago29

[qwertz1]

3. I saw on here that a couple of you have gone to Costa Rica to get this done-Specifically Dr. Oscar Reiche Fischel- If you have gone there for this type of surgery, or know someone who has, I would be so grateful if you could share your experiences with me- Given the cost of things, it might be the only realistic alternative at this point.

in case you end up paying out of pocket but decide against costa rica also consider other countries. I dont know anything about dr. reiche, but it seems to me that its not that orthognathic surgery in costa rica is exceptionally inexpensive, but that the US is exceptionally expensive.

as an example, in a state-run hospital in germany: about 7000 EUR, including surgeon, hospital, for both jaws. if you use a private surgeon about 15000 EUR.

Ive also heard that paying out of pocket can be very inexpensive in england, because they do it on the side of their NHS job. maybe you can get a similar deal in canada.

anyway, just spitballing, good luck getting it approved in the US!

[Christina28]

Other posters have given great suggestions, just to add to that a bit I'd advise you contact your state insurance dept. Some states have laws explicitly stating that insurance companies can NOT exclude this type of procedure. I believe CA is one of them. All the other states vary, but this is one thing to look at. This may open up more possibilities for you.

Also some hospitals will give you "cash pay" costs which may be more feasible for you. The fees for OS will vary greatly depending on surgeon but also depending on area you are in. High cost cities, will have higher cost surgeons for example. Perhaps you could travel to an area with more reasonable costs if that is an option for you.

Finally, many surgeons will offer low rate or zero interest financing such as Care Credit. You still have to pay, but at least you have more time to do it in. Best of luck.

[at long last]

Get HR to help out. They have a lot more leverage in terms of getting things approved since they have the "power" to change providers...my old HR department helped me get all my payment from the insurance company even though I was no longer employed there.

Also, I had double jaw surgery (with insurance). The surgeons fee was about $21,000 and the hospital bill was $25,000 for 2 nights. I'm sure that the $25,000 was negotiated with the insurance company but you may be able to do some negotiation even if it's out of pocket. Also, don't be afraid to negotiate with the surgeon. I did with a smaller portion that I was responsible for (but only works if it's out of your pocket/out of network and not the insurance company's required co-pay, deductible, etc.)...

[I love my teeth]

Just went through this yesterday at my surgical records appt. found out during my appt insurance denied.....Dr. Bloomquist in Seattle has very, very low private pay fees. My pay in advance private fee was 8K (that's everything--hospital, surgeon, and anthesia costs).....I will still fight with the insurance company, but I am glad the private pay was "reasonable" and now I am paid and all set....surgery is Jan 17th---then I will submitt to the insurance co, and fight like hell to get some of my money back! good luck!

[hduggan]

That seems very low for a price that includes hospital fees. How is he able to bargain those kinds of fees with them? Or is he doing it in an off-site surgical center?

[I love my teeth]

I don't know how, but I didn't ask......it's at a regular hospital.....he does a lot of business I think. He switched hospitals from 2010 to 2011 because he could negotiate a better rate at one over the other. His fee was about 3500, hospital was about 3700 and anesthesa was about 800....give or take a bit. I agree a great price for a top surgeon--who is obviously not too money greedy!

Forgot to mention I am having BSSO only...which seems in the world of orthognathic surgery the easiest and least expensive of all the surgeries. I assume his fees change with the amt of work he has to perform.

[24braceface]

The insurance game is tricky. The first thing I would do is find an oral surgeon in your area and consult with them. They will contact your insurance company to see how much of the procedure will be covered. Generally speaking, if it is out of network it will be 25 to 35% of the surgical costs. If it is in network, you only have to worry about your deductibles and/or co-insurance.

If your insurance company explicitly excludes orthognathic surgery, then there isn't much you can do. However, if it isn't excluded, leave it to your surgeon's office to figure it out. That's what they do and that's what you're paying them for. They know how to play the game. And yes, I say "game" because that is what it is. They have to use the right terms in order to get it covered under medical. Personally, I think it is insane that they have to jump through hoops like this, but many insurance companies view this as purely cosmetic and that's a shame. A bad occlusion is a medical condition just like anything else.

If this route doesn't work for you, your other two options are medical tourism (i.e., Costa Rica as you suggested) or a university teaching hospital. Both of these will be significantly lower cost. There are people on here that have done Costa Rica with Dr Reiche, and I believe overall that people are happy with that outcome. A university setting is what it is - You're going to have medical students in on the procedure, but obviously somebody experienced would be directing the show and would be involved. You will need to determine if this is something you can handle. I know people that have done the surgery in this setting and their outcomes have been great.

Just a rough idea of what all of this can cost with a private practice surgeon:

- Upper/Lower Surgical Fees: $12,000 is the cheapest I've heard - The most is over $50,000 if you go with one of the "rock star" surgeons. I'd say $20,000 to $25,000 is normal range. The fee is split more or less so if you only need one jaw done, you could figure half these amounts

- Hospital: Likely around at least $15,000 inclusive of the OR fee, drugs, equipment, etc. If you add other nights this will go up significantly. I was in hospital for 3 nights and my insurance company was billed upwards of $48,000. Now, this is what is BILLED. Your insurance will pay far less assuming you stay at a network hospital, and if you had to pay cash I'd try to agree to about 25% of the billed fee in advance of the procedures

- Anesthesia: Depends on how long the surgery is. An experienced private practice surgeon can do an upper/lower in 3 to 4 hours. A university setting can take 6 to 8 hours. Generally, it is around $1000.00 per hour you are under

My best advice is to stay strong and fight like hell, and be prepared for a lot of research, paperwork, etc. If you do this, you can probably get the insurance company to pay. Just don't think it is going to be easy...

Best of luck to you.

Regards
Chicago29

What is the point in going to a university setting if it's still expensive? I'm referring to the comment you made about how it's $1,000 per hour while you are under.

[chicago29]

The costs I quoted are in regards to a private practice surgeon, private practice physicians, and a "for profit" hospital. I have no idea what costs are associated with a surgery done in a university setting. However, I would think that there are SOME costs that are still going to be your responsibility, albeit they should be much less.

[embervine]

Thank you all for these suggestions- This is so helpful! I went to the surgeon today and I will need upper and lower done for sure, total cost is going to be between $30-40 for everything, excluding braces, another $6000. Not to mention, doing this without insurance means that if there are any complications, you are on your own. Dr. Foley (my oral surgeon in Bouldler) told me that he has never, in his 30 years of experience, seen BCBS of Colorado cover the procedure, sigh. But, as one of you wisely suggested, I will work with HR and see what, if anything can be done.

Interestingly, the doc, who has done many, many of these surgeries, told me that 25 years ago, all they used to have to do to get this approved was call the insurance company and tell them it was medically necessary and it would be approved- They didn't have to write any letters or anything. What happened of the last 20 years??? Why is it that if you are born with one leg longer than the other it will get fixed no problem, but if your upper jaw is underdeveloped, or your lower jaw is over developed, and it causes functional impairment and discomfort, it is considered "cosmetic" and so many insurance companies don't pay for it?? It's a bunch of crap! It makes no sense, the only thing that could explain it is the owners and shareholders of the ins companies look to find any loopholes they can in order to make their profits higher-We can't help how we are born though, and why is it that a functional problem with my face isn't considered necessary to fix, despite all of the literature and medical opinions of oral surgeons? Why are the insurance companies getting away with this? It is criminal. Our insurance costs $300 per month each, it is good insurance, and it won't cover anything that I need done. So, I have to pay for the surgery, if it doesn't get precertified, which the odds don't look good- AND I have to keep paying for this worthless insurance. And now, if I try to get individual insurance, this whole thing will be considered a pre--existing condition, and they will not cover it because of that. Like I am a car with a broken radiator or something.

I would love to see in my lifetime, the insurance companies treat patients like they are human beings. I am not sure how legislature needs to change in order to enable this, I just know that it does. For all of you who responded and are facing/have faced/or will face these challenges, my heart goes out to you.

[azjaw]

What did you end up doing? I am considering going to Costa Rica to have the surgery done by Dr. Reiche so if you went that route I would be very interested to know what your experience was like.