Brandy's Braces, SARPE, Jaw Surgery Journal

This is my daily journal to my eventual perfect smile and Apnea free life. It logs my surgeries, and daily progress.

Thursday, March 08, 2007

Insurance Woes

Man, just a few months ago I was complaining about how far away May was. Now, yet again, I'm grateful that I still have a few monhts to spare. Called my insurance manager to check on my pre-auth today. She had submitted all the paperwork I gave her (new medical necessity letter, new treatment plan, and all the previous info etc.) So she had recieved an email back from them saying that it would still be covered. I also talked with her about the possiblity of having genio covered. That the doctor had said that he would be doing it to help correct my sleep apnea, and that it does have functional benefits to it, that it changes the pull on the tongue. He had not put it on the new treatment plan so I wanted to know what to do. She told
me that the doctor could submit a new pre-auth for the genio, or add it to the current one.

So armed with the new info and the email approval I called my OS to schedule my surgery. I spoke to the nurse, who said she needed to pull my chart and asked if I could hold on. She came back and said that she wasn't sure how much time the doctor was going to need and that she needed to consult with him first, and get approval from him to schedule it, then she would call me back. She then tranferred me to the insurance clerk so I could talk to her about the genio pre-auth.
The conversation went something like this:

Girl: Hi, this is ____

Me: Hi, ____ this is Brandy, hey I wanted to ask you. When I picked up my new medical necessity letter it said that the Dr. may perform a genioplasty, however, it is not on the pre-auth treatment plan.

Girl: Oh..yea, that is not covered. Anything with the word "plasty" sorta freaks the insurance companies out. They consider it cosmetic and won't cover it. So it will be an additional $3500.00. So, you understand that it will be 30% of the procedure which is $7,000 plus 3500.00 so $10,500 to be paid before your surgery date.

Me: But, the Dr. told me that he wanted to do it because it changes the pull on the tongue. Not because it's cosmetic. My insurance manager said that I should submit a pre-auth and that when they investigate the procedure if there is support for this functional use, that they can override it and approve it. Also I got an email saying it is covered, and my insurance pays 100% after I pay $1,000. So this would all be covered.

Girl: Yes I know that, but this is our office policy and so when the insurance pays us we just cut you a check and pay you back the rest.

Me:, I thought we talked last time and you said that if my insurance would cover the whole procedure 100% that maybe we could reduce the down payment to $4,000 instead of $7,000.

Girl: Yes that might be true, but we need to have a paper copy of the pre-auth stating how much they are going to cover. Not just that they ARE going to pay.

Me: But that doesn't make any sense, why would the insurance company tell you how much they would cover? I mean aren't they going to be afraid that if they say they will cover $80,000 that you will charge $80,000? I mean really the doctor doesn't even know how much he is truly going to charge until he gets in there and does the work.....right????

Girl: Well I'm just telling you if you want to pay $4,000 instead of the $7,000 then that is what we would need.

Me: Ok...fine, I will call the insurance agent back again and ask if this is possible. But truthfully I couldn't care less about the down payment. I mean if I Have to put $7,000 on my credit card to proceed with the surgery, when my insurance has said they would pay 100% then so be it. I'm not worried about getting my refund, I know the insurance manager I'm working with will make sure it gets paid for me.

Girl: Ok...then, I will have the Dr. write up a new letter of medical neccesity for the genio, and we will submit a separate pre-auth for this procedure also.

Me: Great, if you will just call me when you have those ready to go then I will come pick them up, and take them to my insurance lady. She wants to hand process all my paperwork so we can keep everything together.

Girl: Ok, I will call you when they are done.

Me: Thanks, Bye. you can see, it was a lot of drama for something that is supposed to be relatively simple. I guess I'm confused here. I mean if a person has this jaw surgery because they have occulsal issues isn't it also considered a medical prodedure? I mean isn't it covered under ones medical insurance? I feel like I'm so confused now. It's insurance company voodoo I tell you!


  • At 8:59 PM, Blogger Mrs. Shanton said…

    Woy...that's a lot of work. An exercise in patience AND assertiveness. Nicely done, Miss Brandy. I think the insurance company is staffed by people who don't give a damn but they do have one directive; deny, deny, deny. Finally, when you make it worth their while to get rid of you, they pay. Gotta be squeaky, though.


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