Is this right - Gunson/Arnett

[I love my teeth]

My insurance denied originally, my surgeon has low private pay rates...just got my itemized hospital bill --1night in hospital, $16,000.....I paid a private pay rate of $3750...that's pretty darn good!

I paid the surgery privately, then submitted to my insurance agian, hoping they will pay--out of pocket it was about 8K, hoping to get about 5K back--fingers crossed!!

[chicago29]

The ability to "appeal" an insurance payment verdict regarding surgical fees for Arnett/Gunson is going to be rather limited. They are out of network for most carriers, and even where they ARE in network I can assure you they aren't going to subscribe to the insurance company's payment schedule. That means a lot of it is coming out of your pocket.

The insurance company doesn't care that they are perceived to be the best...The fact is their surgical fees are practically double everybody else's, and if you want you surgical fees covered you're going to need to find a provider in your network. In the insurance company's eyes, any OMS can do this surgery. I completely disagree with that, but it's the truth.

By the way, this problem isn't exclusive to these guys. It seems to be the case with many orthognathic surgeons. The trend is definitely away from being an in-network provider because the insurance payments don't cover anything close to the actual billed fees.

I don't like the trend myself, but I understand it. If I were a surgeon, I'd rather do 1 surgery at my preferred fee structure than have to do 5 of them and get paid the same amount as if I had just done the one and not had to mess with insurance companies.

-Chicago29

[CaliforniaKid]

The ability to "appeal" an insurance payment verdict regarding surgical fees for Arnett/Gunson is going to be rather limited. They are out of network for most carriers, and even where they ARE in network I can assure you they aren't going to subscribe to the insurance company's payment schedule. That means a lot of it is coming out of your pocket

I'm well aware of their unique relationship with insurance companies. I've considered the cost of the surgery and potential benefits, and realized it isn't a huge difference in the long term.

All the other local surgeons I met with had no luck in managing any compensation from my insurance. And they weren't world famous like Arnett.

My main concern is having to pay more than the estimate Arnett gave me. I don't like the idea of dealing with an unexpected hospital bill or additional procedures not originally diagnosed to I needed them on the day of the surgery.

The concept of my payments doubling is a very scary thought...

[qwertz1]

I was in a similar situation with another surgeon. Is anyone aware of some kind of insurance that covers complications that you can buy before surgery?
it is probably unlikely this exists because it would be quite hard for the insurance company to assess the risk, but on the other hand I would pay hugely overpriced premiums just to get rid of this risk.
I know a patient who had to stay 2 weeks in the hospital because of complications. I can't imagine the bill then...fortunately she wasn't paying out of pocket.

[hduggan]

Does your insurance policy not cover the surgery? If it doesn't, I believe that means that it also won't cover complications from the surgery.

So, when we thought we were going to lose our insurance right after my son's surgery, we were told that a new insurance policy wouldn't cover complications from any condition which it excluded. So, if he went in for jaw surgery and got a secondary infection from the surgery, a new insurance policy which excluded jaw surgery would also exclude the secondary infection arising from it. As long as the complication is somehow tied to the excluded condition, insurance won't cover it.

Fortunately, we were able to stay on the insurance plan which had originally approved his surgery.

[ColoradoGirl]

My hospital was $78k, but insurance paid it. My double jaw was 35. Still working with the insurance on that one. PM me again if you like!

[qwertz1]

Does your insurance policy not cover the surgery? If it doesn't, I believe that means that it also won't cover complications from the surgery.

of course. what I meant was insurance specifically for complications, i.e. you pay a higher price than what is quoted but they cover the risk of complications.
this does exist for some types of plastic surgery but I've never heard of it for regular surgery.

[treevernal]

So it seems to me the typical payment scenario for surgery with Arnett/Gunson (if insurance deems you medically necessary) is for the hospital/anesthesia to be mostly covered (perhaps with a small co-pay) and for about 10% of the surgical fees to be covered. From what I've been reading about what his patients have posted, this seems to be correct; but please correct me if I am wrong!

Btw, for Arnett/Gunson patients, what about the materials fees from the hospital after surgery? Could you give an estimate as to the cost of that?

Thanks,
Dan

[CaliforniaKid]

So it seems to me the typical payment scenario for surgery with Arnett/Gunson (if insurance deems you medically necessary) is for the hospital/anesthesia to be mostly covered (perhaps with a small co-pay) and for about 10% of the surgical fees to be covered. From what I've been reading about what his patients have posted, this seems to be correct; but please correct me if I am wrong!

Btw, for Arnett/Gunson patients, what about the materials fees from the hospital after surgery? Could you give an estimate as to the cost of that?

Thanks,
Dan

what do you mean by materials fees?

It's about $2,000-8,000 for blood...I don't know about anything else.

[Marisama]

Hi everyone, I too am hoping to have surgery with Dr. Gunson. Would one of the Gunson patients mind posting a complete financial breakdown?

[treevernal]

Californiakid, I think you mean $200-$800 for blood. That's what it says on my quote anyway. Please let me know if yours was different because $2000-8000 for blood is ridiculous.

[CaliforniaKid]

Californiakid, I think you mean $200-$800 for blood. That's what it says on my quote anyway. Please let me know if yours was different because $2000-8000 for blood is ridiculous.

Yes that is what I meant.

[Summertimeolive]

Hello ! I was looking to connect with anyone who has had the surgery with this team- I just consulted with them recently and have a million questions!

Thanks

[maxhammer]

Does anyone know if Dr. Eric Wallace in Santa Barbara is good?

[SantaBarbarian]

Hello,

This is the first item that pops up when you search for "arnett gunson cost." I see all the information on here, while good, is fairly old and deserves an update. I had surgery with Dr. Gunson on December 2, 2015 - 18 weeks ago tomorrow. I'm still fighting with my insurance and will try to post an update when it's done (could be months), but here's the details I can share at this time:

-I have a PPO through my employer with Cigna. I hate Cigna beyond belief, but that is another story (ok, that is many other stories...).
-Upper and lower jaw surgery to pull both jaws forward to correct severe sleep apnea. I'm 33, 6'2", and weigh only 165 pounds, so sleep apnea was not at all related to being overweight. After seeing numerous specialists over the course of several years, and trying numerous other methods to treat the problem, it became starkly clear that double jaw surgery was the only way to fix the problem. My upper jaw split into three pieces (I think that's Leforte III but don't quote me). I was a high-risk patient due to my maxilla bone being "scary thin" as Dr. Gunson described it. I was told that there was a possibility that I could wake up and be told that I could not talk for two weeks due to complications resulting from the very thin bone. Fortunately, that did not happen. I was told the surgery was expected to take 5-6 hours and it ended up taking 8.5 hours due to a complication during the surgery.
-Surgical fees alone (for Dr. Gunson, the assistant surgeon, the splint, etc.) were estimated at approximately $55,000. This included about $5k for cheek grafts because pulling my jaw forward would make my cheeks look sunken by comparison. Insurance does not cover anything that they consider aesthethic, so there was no hope of getting insurance to cover this. I'll provide more info below.
-Orthodontics have cost $6,000 so far. This is not covered under medical insurance and I do not have dental insurance that covers these services for adults - only about $1500 for my future children.
-I had a one night stay at Goleta Valley Cottage Hospital. It is in-network with my insurance provider (Cigna) under my plan. They charged something like $127,000 for the 8.5 hours in the operating room plus a 1-night stay. I expected insurance to discount this by 75%, but I wonder of Obamacare has changed things, because Cigna paid all but $12,000. Because I had already met my maximum annual out of pocket expense for in-network providers, GVCH was under contract to accept the ~$12,000 discount and I did not pay a single penny.
-Dr. Funk, the anesthetist, charged $7,500. He is an out of network doctor but, because the work was done at an in-network facility, Cigna paid the in-network rate, covered this in full, and (again because I met the maximum annual out of pocket expense before the surgery) I didn't pay a penny.
-Because I live in Santa Barbara I did not need to worry about hotel expenses.

So, the only thing I really had to pay for was orthodontics and Dr. Gunson's (and the assistant surgeon's) surgery fees. I live in the Santa Barbara area and, because there are no in-network jaw surgeons within a 25, 50, or 75-mile radius (I forget which number is the number they use as a cutoff), I was successful at getting Cigna to make a Network Adequacy exception (other insurance providers can call this GAP coverage) for Dr. Gunson to allow him to be covered at the in-network rate (meaning that they would use my in-network deductible, maximum annual out of pocket expense, and percentage pay rate, all of which is more favorable than the out of network rates). One thing they do not mention but I know from previous experience: in their official letter authorizing the Network Adequacy exception for Dr. Gunson, they DO NOT mention that payments are subject to the Maximum Reimbursable Charge (MRC). The MRC is how they prevent having to pay if an out-of-network doctor over-bills (since the out of network doctor can charge whatever he/she wants and is not limited by a contract with Cigna). The MRC is based on a multiplier (in my case, under my company's plan, just 1.1 times) the Medicare rate! We all know that doctors are refusing Medicare more and more due to its low reimbursement rate, and this is essentially what Cigna will pay. Worse yet, Medicare classifies Santa Barbara as a rural area. So, despite the fact that it's absurdly expensive to live here, my insurance will only pay 10% more than Medicare would pay to have this surgery done in the middle of Kansas.

There one other important factor in this. Namely, Dr. Gunson's surgical fees are a single, one-time fee for the surgery plus ALL pre-op plus a LIFETIME of post-op care. This is EXTENSIVE care, which helps to explain why the fees are so high. Under normal conditions, he will continue seeing you for two years (though frequency reduces as time goes on as long as things are going well - down to just once per quarter at the end). In my case, however, I've had probably tripple the amount of normally expected post-op care due largely to my very thin maxilla and some other (minor, fixable) complications with orthodontics. (Because I had severe sleep apnea, Dr. Gunson agreed to operate before my orthodontic treatment had finished, which is not how he prefers to do things but all agreed it was important to correct the sleep apnea sooner than later).

The problem? Insurance companies do not operate the way Dr. Gunson's office bills. Namely, insurance companies expect to receive a bill for each individual service provided, every single time. The phenomenal amount of post-op care I have received has not cost me an extra dime, but you can bet that Dr. Gunson's initial fees accounted (to the best of his ability to predict) for me to have a lot of post-op care (that, or his overall fees average this out across all patients). Regardless, despite the huge sticker shock (I felt it too - its more than my entire take-home pay for a year), I think his fees are actually reasonable given the amount of follow-up care he has provided. If I had to pay for each of these visits individually (a la carte, so to speak), it wouldn't be affordable at all. You definitely are getting the "combo plate" with this fee.

Point is, if you were to pay for each visit individually over the course of two years, it would be a tremendous amount of money, which is why the fees are so high (in addition to him being a world-class surgeon), and insurance companies do not normally pay for services this way. Knowing that, I worked with the head of my company's HR department to work with Cigna to get an agreement that they would pay at least the MRC (which we all know is low) for these services, since I did pay for them in full as part of the surgical fee. This is what the current fight is about with Cigna, as they have reneged on their promise to pay. I also had to fight Cigna to pay the assistant surgeon at the in-network rate (which the ultimately did) AND I had to fight Cigna to pay me the full MRC for even just the surgery as they wanted to pay just $5k (the amount they would give to an in-network provider). I couldn't believe it when their representative said that they would only pay $5k because I'd requested the in-network rate; the reality is that that representative was wrong, and once you show Cigna the bill, they will re-process it so that they pay you the lesser of either the MRC or the bill. I would say that it's dumb that they don't do pay this larger amount immediately, but of course they want you to hopefully accept the smaller amount without realizing that you can and should be paid more.

Also! I need to point out that the estimate for the surgery was $55k, but it ended up being a hair less. Certain line-item costs were increased due to the complications during the surgery, but for whatever reason Dr. Gunson didn't need to spend $5-6k on a splint, so I got a net refund of about $2k from Dr. Gunson. They are an upstanding, very honest group of people!

COST AND REIMBURSEMENT SUMMARY AS OF TODAY:
Orthodontics: $6,000, paid in full by me.
Anesthesiologist: $7,500, paid in full by insurance with a small fight. (Incidentally, Dr. Funk would accept just $3,075 if you paid it in cash).
Operating Room and one-night hospital stay: $112,00-$125,000 (I forget the precise number), paid in full by insurance without any fight. This was amazing.
Surgery: about $53k, about $48k of which was billed to insurance split between a limited number of pre-op procedures (three, I think), 2 procedures under Dr. Gunson, and 2 procedures under the assistant surgeon. Combined, Cigna paid me the full MRC for these procedures which came to about $24,000 with multiple, medium-level fights. If I can get Cigna to pay for the additional pre-op, and the many post-op, procedures that have been provided to date but not yet allowed by Cigna, I expect that will be worth upwards of $15,000, but so far this has shown to be a humongous, ongoing fight. If I'm right and successful, Cigna might end up paying about $38,000-$42,000 of my $53,000 surgery; at least I have $24,000 so far.


Other random thoughts:

-It took me a year to fight my insurance to authorize my surgery due to three false negative sleep studies (I would wake before the 10 seconds of not-breathing required to count a disturbance as an apnea). This was all done before I even saw Dr. Gunson as I was trying to work with another surgeon, but ultimately unselected that surgeon at Stanford due to issues related to communication. Apart from the Stanford surgeon, my experience at Stanford was superb, and it was Stanford's sleep clinic and Dr. Pelayo (I cannot ever say enough good things about Dr. Pelayo - he's so amazing, helpful, and calming) that I a true positive sleep study result for apnea and then got my surgery covered.

-I advise calling your insurance company to go over ALL of the details, ask about in-network status, etc., and record the person's name, time and date for the call, and get a call reference number.

-While Cigna records all of their calls, when you ask about a previous call, they will look at the notes that the representative provided. If the representative did not provide include the necessary details (or, in some cases for me, noted something that was the opposite of what we talked about!), Cigna will have to take several days to review the actual recording of the call to determine that what you say that they told you really is what they told you. Once they confirm that, they will usually, but not always, honor what they told you.

-Follow up with every single bill, before AND after the service is provided, to ensure you're getting the maximum amount possible. Try to get everything covered at the in-network level (and understand that there is an MRC for out of network providers even if the service is covered at the in-network rate). Get the procedure codes from your providers (Dr. Gunson, Dr. Funk) and ask your insurance company what the MRC is for each procedure. That way, when they tell you that "$5k IS the in-network rate," you'll know that that's a complete lie because the in-network rate is the full bill that is only capped by the MRC (which is bigger than what they'll try to pay at first).

-If you need any other medical work done (e.g., I needed custom-made orthotics for my feet, unrelated to the surgery), try to get that work done in the same year as your surgery so that it can be provided "for free" as you will hit your maximum annual out of pocket expense if everything is covered at the in-network rate.

-Dr. G is a phenomenal, gifted surgeon that demands utmost perfection in his work. He is also extremely caring, compassionate, and willing to give you as much time as you need. I would not put my life in the hands of any other person. I believed this before the surgery, and now having gone through it, I'm so incredibly thankful that I chose him - nobody else would give me the care or outcome I needed.

I post some other details about my experience on my blog. Just Google "Chris's Jaw Surgery 2015" (though I admit it hasn't been updated in a while).

This was a long post but I hope it is helpful for someone out there!