Did Insurance Help Pay for Your Surgery?

[INBC]

No, I was told that my bite wasn't severe enough for coverage under BCBS in the U.S. One oral surgeon I saw even tried to steer me away from surgery because he was certain that I wouldn't be covered. Now that I'm in Canada, provincial health insurance will cover some of the surgery but I will still be responsible for the surgeon's fees and cost of braces beforehand (but my private dental insurance will cover $3k of that).

[Kzamor12]

[quote=samoorelaw post_id=461272 time=1422778335 user_id=21779]
United Health Care paid for mine but not without a long, hard fight (took two appeals). Good luck to you on getting yours covered.
[/quote]

How did you manage it get it covered? I'm having a lot of trouble with united healthcare. My doctor is a out to start the appeal process. Please share your journey?

[eh1253]

[quote=Kzamor12 post_id=503295 time=1531437844 user_id=32171]
[quote=samoorelaw post_id=461272 time=1422778335 user_id=21779]
United Health Care paid for mine but not without a long, hard fight (took two appeals). Good luck to you on getting yours covered.
[/quote]

How did you manage it get it covered? I'm having a lot of trouble with united healthcare. My doctor is a out to start the appeal process. Please share your journey?
[/quote]

It looks like they want your bite to be over a specific amount from the norm in combination with having an approved functional impairment due to the bite being off. (At least according to this doc: https://www.uhcprovider.com/content/dam ... urgery.pdf)

So maybe play up the functional impairment side of things?

United Healthcare did agree to cover mine so they are willing to approve sometimes. It took about a month to process and pre-approve with no appeal needed. I guess I got lucky or my bite just really sucks.

Anyway, not sure how helpful this is but I just wanted to give you some info since I have UH. We aren't super far from open enrollment so maybe you can switch to a provider in November that approves these easier if all else fails?

[Kzamor12]

Thats going to be my second option, to switch insurance but I honestly can't afford it. If I clam to have sleep apnea, do they require the actual sleep study to be done? What was your "functional impairment"? Because I don't have cancer, tumor, or trauma so they call it cosmetic -.- which is stupid because my teeth are cracking from the severity of the bite and I have a speech impediment.

I appreciate your reply, by the way, it's pretty lonely when you're the only one in the family with a jaw problem. No one gets it.

[eh1253]

[quote=Kzamor12 post_id=503310 time=1531500663 user_id=32171]
Thats going to be my second option, to switch insurance but I honestly can't afford it. If I clam to have sleep apnea, do they require the actual sleep study to be done? What was your "functional impairment"? Because I don't have cancer, tumor, or trauma so they call it cosmetic -.- which is stupid because my teeth are cracking from the severity of the bite and I have a speech impediment.

I appreciate your reply, by the way, it's pretty lonely when you're the only one in the family with a jaw problem. No one gets it.
[/quote]

Yeah I know what you mean. My family has been really supportive through this whole process but they can't really relate and I think they do get tired of hearing about it.
I THINK my impairment was sleep apnea combined with my bite being > 2 standard deviations from the norm. Honestly I'm not sure if my surgeon included sleep apnea in the request :/ I didn't have to do a sleep study on it but it probably wouldn't hurt your case.
The extra wear on teeth was also my main motivation. I really don't want to have to go the dentures or implants route and just have this slowly get worse as I get older.

[Kzamor12]

So I literally just got a call from my doctors office and they said they won't work on the appeal. I have to do it by myself. I don't know what to do. I'm scared that they'll make me do a sleep study if I say I have sleep apnea. How in the world did they approve it for you?? Ahh. I'm going crazy.

[eh1253]

[quote=Kzamor12 post_id=503316 time=1531508257 user_id=32171]
So I literally just got a call from my doctors office and they said they won't work on the appeal. I have to do it by myself. I don't know what to do. I'm scared that they'll make me do a sleep study if I say I have sleep apnea. How in the world did they approve it for you?? Ahh. I'm going crazy.
[/quote]

I'm guessing coverage just varies a lot by plan or company. Also I think my bite is really bad.
I'm really sorry that you are in this position. Have you gotten second or third opinions? Maybe you can find a different doctor that would advocate for you or let you know how viable the alternatives are for your situation. I can't really help with the appeal process but, again at the very least I do think there are other providers that are more willing to cover this sort of thing - but even with coverage it's still really expensive for me (braces aren't covered and my out of pocket max is high). I'm probably spending nearly $10,000 when it's all said and done and that's assuming the medical expenses don't drag into next year :/

[Kzamor12]

Yeah. Braces were/are $5000 for me (no dental insurance). I'm paying 250/mo till January. Not to mention I have to drive 5 hours for my check ups because all of the oral/max surgeons near me are jerks who refuse to do this kind of surgery because they don't get reimbursed as well as they'd like. And I'm doing all of this mostly on my own because my parents released all of their parental responsibilities once I turned 18.

I'm just going to have to work on the appeal. I'm growing more depressed by the second. I couldn't even concentrate at work today. I called my doctor back and asked how much the surgery would be without insurance and they said $30,000. Great. It's like a car I can't drive OR afford.

[eh1253]

Geez that's a difficult situation. I know your parents cut you off to some degree but I'd really push for them to understand your situation and help out. This is a lot to take on and you could probably use all the support you can get. This is a big deal and it's not the same as making you pay for your phone bill or something lol.
Sorry I can't help with the appeal aspect of this. But it does seem like insurance companies might like to make you fight before finally approving this surgery. Probably not a bad idea to see another surgeon or two and see what they think and if they have any advice for the appeal process (I guess not so easy when they are 5 hours away). Hopefully someone here can chime in on appealing to insurance.

[academiannut]

I spent a lot of time trying to figure out how much my insurance (Aetna) might pay for a non-participating provider, with no success.

OUT OF NETWORK:

If you're going out of network, this is what I learned:

You want insurance that says it uses usual, customary, or reasonable pricing. Search any of those terms. If you can't find them, search for "medicare."

It turns out, every insurance plan my fiance or I had available to us through our jobs does state, near the end of the brochure, what they pay to out of network providers, and in all cases, it was a percentage of medicare coverage (or - almost nothing). I didn't find this out until months after I'd started researching it.

If you are looking at doing this out of network, you want to see if you can find insurance (if there are any left!) that use fair health pricing or usual, customary reasonable pricing to determine their payouts.

If not, they must list somewhere in their brochure what percentage of medicare costs they use to determine out of network costs. For my plan, the number was about $1,750 after deductible that they'd pay out of $25,000 of surgeons fees - terrible. But neither I nor my doc's admin assistant were able to figure this out in advance. I just didn't know what I was looking for.

Turns out I may get about 12 k from them after all, because they sent us a notice saying that they were going to pay their in-network rates rather than the rate than listed in the brochure. Awesome for me, but I have no idea why. Is it because I paid for the more expensive Aetna option or would I have gotten the same deal on a cheaper one? No way to tell, no way to know,.

My only guess is that either 1) the complexity of the surgery justified paying for an out of network provider at in-network rates, or 2) the company is required to offer insurance that covers about 60% minimum of health costs and so they had to pay more?

Not sure. The frustrating thing is there was no way for me to predict what they would pay correctly.

But if you're going out of network, find the part of the brochure that lists what scale they use for out of network, whether its based on medicare or usual, customary, reasonable pricing.


APPROVAL:

I will say, I had zero trouble getting approved with Aetna. Quick and easy. And I had no bite issues!

My doc did have me do several things in advance.

1) I went to a speech therapist who document slight slurring of speech.
2). I did a sleep study, which documented mild apnea.
3). I went to an ENT. I had already had a septoplasty but he documented need for reduction of turbinates.
4). My doc had me write a personal impact statement.
5). Doc also sent in cephs documenting that my jaws were 2 standard deviations below normal size, which meets Aetna's requirement for vertical height discrepancy.

Doc wouldn't submit to insurance until I'd done all these things, but once we did, coverage was approved within a few days.

Costs are still higher with Aetna than they would have been with another provider because I pay 15% of all costs (rather than flat hospital fees, for instance). I haven't seen the bill but I'm expecting 3.5 to 4 k for the in-network, 100% covered hospital co-pays. My total coverage will still be more than if I'd gone with a different provider that paid more of my co-pays but only covered my surgeon's bill at medicare rates...

but I have no idea if another insurance company would have also felt compelled to pay at in-network rates or not. Health costs are always a guessing game in the U.S. It's three weeks after surgery, and I STILL don't know what my actual final costs are, not even within a few thousand dollars.

In conclusion: My experience was that it is just about impossible to predict your total costs in the end in the U.S.A. And we really need a better health system. But do the legwork in advance to make approval easier.

[Guiana]

Anyone tried with Independent blue cross?