Re: Diane in Oregon

[Guest guest]

Hi Connie,

I have BCBS of Oregon through the State of Oregon. When I talked with BCBS

last fall, they indicated that if the procedure were deemed medically

necessary, they would cover a percentage of what they called usual and

customary expenses (or something like that). It sounded like usual and

customary expenses would be about a third of the cost. Their percentage

would be taken off from there. However, all insurance contracts are

different - even within BCBS. To make matters worse, I'm having the surgery

done in Washington State.

At my initial consult with my OS in early November, his office said BCBS of

Oregon was known to deny orthognathic surgery claims. We went ahead and got

a second mortgage for the braces and surgery so I could plan for my surgery

and not be too stressed about how we were going to pay for it. I'm in the

process of filling out a questionnaire the surgeon will send to the

insurance company. Before I do, I'm going to have a sleep apnea study done

after tax season (my husband is a CPA). I believe the snoring is due to my

jaw receding and may help with the medical necessity designation.

I've been in braces two weeks today!! I'm hoping to have surgery in the next

year. At this point, it's lower w/possible upper.

As I find out more from insurance, I'll let you know!

Good luck in your journey. Please let me know how your insurance claim works

out.

Diane

_____

From: connieberrymama

Sent: Saturday, March 26, 2005 1:03 PM

To: orthognathicsurgerysupport

Subject: Diane in Oregon

Hey, thanks for the good wishes on my surgery. I was wondering what

sort of health insurance you have, and if you have found out whether

or not they are going to pay for your surgery. I recently signed on

with Regence Blue Cross/ Blue Shield even though they listed

orthognathic surgery as an exclusion in their handbook. I was

actually just hoping to possibly have part of the hospital bill paid

for. When I received the new member handbook they said that there are

several instances in which they will pay for the entire surgery,

including my OS. Wooo,hooo! So my OS' office is sending off the

forms for pre-authorization. I'm waiting on pins and needles to find

out. This surgery has been a matter of prayer for years, and we've

thought all along I would have to pay out of pocket for everything.

Wouldn't it be great if I didn't have to take out a 2nd mortgage and

max out credit cards to have a great smile? Just wanted to know what

your experience with Oregon medical insurance has been.

Connie

[Guest guest]

This is all for folks in the U. S. of A. Sorry, to all others. I

don't know your systems nearly as well.

A little hard-won help in deciphering all this...

" Usual and customary " for BC/BS, here, anyhow, is what they will pay

for a specific procedure. (It turns out to be " surgery " when I have

cortisone injections in my wrists or thumbs for arthritis. Also CT

scans, x-rays, dental work, eye exams, you name it. Anything in

hospital, or in the Emergency Room is different. With different

deductibles, as are therapies of assorted types.)

The short cut is that this is the fee that BC/BS authorizes in your

individual policy (and maybe in all policies) for payment for a

specific service. If your caregiver is a preferred care provider, he

or she has agreed to accept this amount as full payment for that

service. If not, he or she is at liberty to charge you the full

amount; BC/BS will pay their approved fee, and you are responsible

for the difference.

They always tell me how much " I saved " by using a preferred care

provider.

" Usual and customary " are almost invariably the lower amount they

will pay. I grieve for those who cannot afford (or even manage to

pay) for coverage that gets them such breaks, as they are often

huge! And the charges BC/BS is billed are often many times

the " usual and customary " charges.

You do not want to know how I know this.

If you can work with a surgeon who is a preferred care provider, you

may find that you save many, many dollars... I did choose to use an

ortho who won't deal with all this, because I could work with him,

because he was near, and because I thought I had the funds to deal

with it. If I'd been willing to drive 70 or more miles each way,

there was an in-network ortho who would have given me the services,

I think, at the rate my DENTAL insurance would have paid. I would

have saved thousands of dollars. I do not regret my choice.

two other options: Check into the provisions in your policy about

exceptions for those who have no nearby providers. Or, get to be

goood friends with your banker, lender, whatever. And, yet another:

Check out a dental school, which might give you a lower rate.

C.

[Guest guest]

Luna,

I'm guessing the highly regarded surgeon you're referring to is Dr. West. I

was quoted about $11,000 for lower and about $21,000 for upper and lower. I

too am struggling because he is not a preferred provider under BCBS of

Oregon, but the surgery facility and I believe the assisting doctor and

anesthesiologist are a PPO.

Did Dr. West's office give you an itemized quote? I'd contact his office and

ask if the facility and/or the assistants are a PPO under your insurance

plan.

I live in Oregon and will be traveling to Seattle to have my surgery. It is

a long way to go, but my orthodontist said Dr. West is the only surgeon he

would recommend!

Good luck. Please keep me updated on what you decide with Dr. West's office

and your surgery.

Diane

>From: str8teeth4me <no_reply >

>Reply-To: orthognathicsurgerysupport

>To: orthognathicsurgerysupport

>Subject: Re: [Orthognathic Surgery Support ] Diane in Oregon

>Date: Tue, 29 Mar 2005 16:45:42 -0000

>