Re: New to the boards - questions about insurance (United Healthcare in particular)

[Guest guest]

Your surgeon knows the codes to put through to have your surgery covered. Work

very closely with your surgeon.

My experience (other issues) is that an appeal is final and binding no matter

the outcome. I learned this on another issue which involved less than $100. So,

an appeal is the last possible resort. Again, your surgeon and your ortho know

what to put through.

emailmaryw wrote:

Hello! I'm new here and just wanted to say what a huge help this

site has been so far. I'm 29 years old and am getting ready to have

jaw surgery for the 2nd time. I had a fairly severe underbite and crossbite as

a child

and had surgery for it when I was 14 years old. It was a pretty rough experience

but I'm

glad I did it. The orthodontist that I've been seeing was schocked that I had

the

surgery so young. My surgeon thought that I had quit growing but - surprise! -

I didn't

and my bite has relapsed over the years. I have my first surgery consultation

this

Wednesday with a Dr.Roser at the Emory Orthognathics Dept in Atlanta. I'm

nervous but

also a little be excited....I've known for a long time that I needed to have

surgery

again and finally feel ready to go through the process all over again.

My biggest concern right now is with insurance coverage. My first surgery was

not

covered (even after many appeals) and it cost over $50K! (I almost died when my

mother

told me how much it had all cost) From what I've been reading it seems like the

prices

have come down but I'm still terrified at the idea of paying for this out of

pocket. I have

United Healthcare and have been looking through my booklet on their exclusions

and

included services - in one section it says any orthgnathics procedure is not

covered but

then somewhere else it says that treatment for TMJ would be covered. I don't

really have a

lot of jaw pain (TMJ) but I wondered - how willing are surgeons to help you out

with

submitting something under a certain code, even if that code does not

necessarily best fit

your problem? I'm just wondering if there is a way to approach this with the

insurance

company that would make it more likely to be accepted?

If anyone has any advice on insurance codes or working with United Healthcare I

would

greatly appreciate it!

Thanks!

W.

[Guest guest]

Hi!

I also have UnitedHealthcare, and so far they have denied my claim twice

because they said that there is " no medical necessity " and that it would be

considered cosmetic. They said that they will give me a final decision on

Thursday, and my surgery is scheduled on Monday! At this point, we have had

so many problems with the insurance (ex. they let amonth go by after I filed

the first step of my appeal, and said that they told the insurance surgeon

to call my surgeon, but he never got the message or had time?) that my dad

(I am still covered under his insurance) has offered to pay for the surgery

out of pocket, and then possibly go through legal process of gett the

insurance company to pay for it after the surgery.... It is very expensive,

close to $20,000 ... Anyone have experience with this? Advice or anything?

Thank You!

Clare

>

> Your surgeon knows the codes to put through to have your surgery covered.

> Work very closely with your surgeon.

>

> My experience (other issues) is that an appeal is final and binding no

> matter the outcome. I learned this on another issue which involved less than

> $100. So, an appeal is the last possible resort. Again, your surgeon and

> your ortho know what to put through.

>

> emailmaryw wrote:

>

> Hello! I'm new here and just wanted to say what a huge help this

> site has been so far. I'm 29 years old and am getting ready to have

> jaw surgery for the 2nd time. I had a fairly severe underbite and

> crossbite as a child

> and had surgery for it when I was 14 years old. It was a pretty rough

> experience but I'm

> glad I did it. The orthodontist that I've been seeing was schocked that I

> had the

> surgery so young. My surgeon thought that I had quit growing but -

> surprise! - I didn't

> and my bite has relapsed over the years. I have my first surgery

> consultation this

> Wednesday with a Dr.Roser at the Emory Orthognathics Dept in Atlanta. I'm

> nervous but

> also a little be excited....I've known for a long time that I needed to

> have surgery

> again and finally feel ready to go through the process all over again.

>

> My biggest concern right now is with insurance coverage. My first surgery

> was not

> covered (even after many appeals) and it cost over $50K! (I almost died

> when my mother

> told me how much it had all cost) From what I've been reading it seems

> like the prices

> have come down but I'm still terrified at the idea of paying for this out

> of pocket. I have

> United Healthcare and have been looking through my booklet on their

> exclusions and

> included services - in one section it says any orthgnathics procedure is

> not covered but

> then somewhere else it says that treatment for TMJ would be covered. I

> don't really have a

> lot of jaw pain (TMJ) but I wondered - how willing are surgeons to help

> you out with

> submitting something under a certain code, even if that code does not

> necessarily best fit

> your problem? I'm just wondering if there is a way to approach this with

> the insurance

> company that would make it more likely to be accepted?

>

> If anyone has any advice on insurance codes or working with United

> Healthcare I would

> greatly appreciate it!

>

> Thanks!

> W.

>

>

>

>

>

>

[Guest guest]

Thanks for the help everyone!

Clare - eeek! That's absolutely what I'm afraid of. I will cross my fingers

that things work

out for you. Hang in there and good luck with the surgery next week!

MW

> >

> > Hello! I'm new here and just wanted to say what a huge help this

> > site has been so far. I'm 29 years old and am getting ready to have

> > jaw surgery for the 2nd time. I had a fairly severe underbite and

> > crossbite as a child

> > and had surgery for it when I was 14 years old. It was a pretty rough

> > experience but I'm

> > glad I did it. The orthodontist that I've been seeing was schocked that I

> > had the

> > surgery so young. My surgeon thought that I had quit growing but -

> > surprise! - I didn't

> > and my bite has relapsed over the years. I have my first surgery

> > consultation this

> > Wednesday with a Dr.Roser at the Emory Orthognathics Dept in Atlanta. I'm

> > nervous but

> > also a little be excited....I've known for a long time that I needed to

> > have surgery

> > again and finally feel ready to go through the process all over again.

> >

> > My biggest concern right now is with insurance coverage. My first surgery

> > was not

> > covered (even after many appeals) and it cost over $50K! (I almost died

> > when my mother

> > told me how much it had all cost) From what I've been reading it seems

> > like the prices

> > have come down but I'm still terrified at the idea of paying for this out

> > of pocket. I have

> > United Healthcare and have been looking through my booklet on their

> > exclusions and

> > included services - in one section it says any orthgnathics procedure is

> > not covered but

> > then somewhere else it says that treatment for TMJ would be covered. I

> > don't really have a

> > lot of jaw pain (TMJ) but I wondered - how willing are surgeons to help

> > you out with

> > submitting something under a certain code, even if that code does not

> > necessarily best fit

> > your problem? I'm just wondering if there is a way to approach this with

> > the insurance

> > company that would make it more likely to be accepted?

> >

> > If anyone has any advice on insurance codes or working with United

> > Healthcare I would

> > greatly appreciate it!

> >

> > Thanks!

> > W.

> >

> >

> >

> >

> >

> >

[Guest guest]

Hi Fran,

I appreciate your concern in the post, and thank you for trying to direct me

in the right way. In fact, this is the third time that I am attempting to do

this surgery with an insurance pre-approval. I have canceled the surgery

twice because insurance would not come through. They seem to be the epitome

of everything evil in the insurance industry, and have surely given me, my

parents, and my parents employer the neverending run-around. I have done

nearly everything you suggested, got second opinions in written letter,

gotten copies of the forms my surgeon sent in, got my dad's employer

involved, etc etc. My dad is actually a lawyer, so it is a little easier for

me than most people to proceed legally should the insurance still deny

coverage. Obviously that is a last option.

I really do not know what to do at this point. I do not like proceeding with

the insurance knowing that ultimately we are going to have to pay for it,

and only potentially getting reimbursed for it. I wouldn't recommend this to

anyone, but I have already canceled 2 surgery dates, and would have to wait

until summer of next year if this one is canceled also. This entire

experience is obviously very frustrating, as my claim is entirely valid, and

I absolutely appreciate your advice! I am really crossing my fingers that

they approve it tomorrow, and I will let you know.

Thanks again!!

Clare

>

> Hi Clare,

> I do not work for insurance, but I have a son with multiple

> disabilities. I have had to fight for years and years with

> insurance and billing offices over clearly appropriate, covered, and

> sometimes even preauthorized claims. I have learned some lessons

> the hard way, and have ended up paying out of pocket for thousands

> of dollars of treatment that were clearly covered, and WERE in fact

> covered when I played the game my way rather than the way they

> tended to lead me. I am going to share some things I have found in

> hopes it will help you. Some of this may sound like I am saying you

> have done something wrong, but I am not saying that at all. I think

> you were led to the position you are currently in, and I think you

> need to change your reactions and call some shots for yourself if

> you have a chance of winning at this point. This information is for

> you if you are denied on Thursday. But some of the steps you can do

> today to be prepared for them on Thursday if you are denied. If you

> are approved, you have nothing to worry about, but if you are

> denied, you will be a few steps ahead of the game. It will also let

> you be better prepared to realize that maybe you do owe. But if you

> don't and you are denied, you need to get busy.

>

> Is medically necessary orthognathic surgery covered under your

> policy - I mean, it is not a specifically excluded benefit is it?

> Has your surgeon verified that your surgery is medically necessary -

> in writing to your insurance, and do you have a copy of that

> letter? Have you been to a different OS to get a second opinion as

> to the medical necessity of this surgery? (and you can call your OS

> to get a rapid referral to another OS to verify his diagnosis - ask

> them to help you with this for insurance purposes, they just may

> make the referral for you). Have you asked your OS office manager

> if your health plan has paid similar claims as yours in the past?

> Has your insurance had your claim reviewed by a panel of qualified

> OS, and not a nurse reviewer or a general practitioner or a

> specialist in an unrelated specialty? For people reading this who

> are new to the insurance process and the OS process, this issue

> needs to be clarified and you need your preauthorization in hand in

> writing BEFORE you do braces!!

>

> Insurance companies are not in the business of healthcare for your

> benefit. They are in the business of healthcare to make money. In

> the past few decades, they have deteriorated ethically to the point

> where their easiest way of limiting their expenses is to deny valid

> healthcare claims. Claims reps are trained in ways to identify

> loopholes and delay tactics to deny your claim. They hope YOU will

> help them deny your claim by not preauthorizing your claim before

> you begin treatment. If you do not do this, they will delay and

> delay and lose paperwork and lose calls, and deny again - hoping you

> will take all the steps necessary to be in the situation you are

> currently in - where you are under pressure to set yourself up to be

> denied and to be forced to pay on your own. This is not a reprimand

> to you by any means. I believe you were led to this position by

> your insurance company policies, but I DO NOT think you should

> continue this path that they are showing you if you are denied on

> Thursday and you have a valid claim.

>

> First, you need to clarify the answers to those initial questions.

> Not just with a phone call verification, but get the answers to this

> in writing. Get copies of the letters your OS has submitted. If

> your plan does cover medically necessary OS, and your surgery is

> medically necessary, and your OS office says similar claims have

> been paid by your plan, AND your claim is denied on Thursday, I

> would NOT proceed with the surgery on Monday. Personally in that

> situation, I would cancel surgery on Monday. You can reschedule

> once you are preauthorized or continue with surgery if it is clear

> you will owe it anyway.

>

> There is no motivation for the insurance company to cover this if

> you take that step on Monday and have been denied on the Thursday

> before. They can continue to deny you and let the hospital put the

> pressure on you and your family to pay the bill anyway - and you

> should know that in fact you WILL owe it!!! The hospital and your

> OS will have your parents sign a form saying you or your parents

> will pay if the insurance does not pay - this obligates you to pay,

> not the insurance company. To put the onus on the insurance you

> need the preauthorization in writing in hand before surgery.

>

> Once your family pays the bill, the insurance company will have no

> overt pressure on them whatsoever to pay the claim, and even if they

> do pay down the road, you can bet it will be a long time down the

> road. It does not even have to go through the same review process.

> So I would suggest you cancel the surgery rather than do this. And

> I am suggesting this only if you are adamant that your insurance pay

> your valid claim and that you are sure you are qualified.

>

> Cancelling will also get your OS on the ball to resubmit more

> information with greater clarity of the medical necessity of your

> surgery. He/she will want to get paid for the surgery, and you are

> ready. You will be putting the pressure on the OS and sending a

> message to your insurance that you are willing to play hardball with

> them. Realize that they are playing hardball with you!

>

> I am sorry for being so direct on this. I have just had way to much

> of this kind of go-round with insurance and health providers, and

> your letter just brought all that back to me this morning. I know

> you are wanting to get this done and over, but if you want some

> financial peace about this being paid you need written backup for

> yourself - and it is a LOT of money here!! Not just this surgery,

> but remember if your insurance maintains this is not a covered

> surgery, and you have complications from the surgery, they will have

> no reason to cover the complications from it either as most

> insurances exclude complications due to uncovered " cosmetic surgery " .

>

> I am just reading over this and it feels strong-arm to me. I am

> sorry about that. That is not my intention. I just have been where

> you are before, and know it is sooooooooooo difficult to clean this

> kind of situation up after the fact. Your best bet, if you are

> denied Thursday, is to cover yourself before you do the surgery.

> And you can start that now in preparation for that possibility.

> Good luck on Thursday. The best case is that you are approved. I

> will watch for your post.

> Hugs,

> Fran

>

>

>

> > >

> > > Hello! I'm new here and just wanted to say what a huge help this

> > > site has been so far. I'm 29 years old and am getting ready to

> have

> > > jaw surgery for the 2nd time. I had a fairly severe underbite and

> > > crossbite as a child

> > > and had surgery for it when I was 14 years old. It was a pretty

> rough

> > > experience but I'm

> > > glad I did it. The orthodontist that I've been seeing was

> schocked that I

> > > had the

> > > surgery so young. My surgeon thought that I had quit growing

> but -

> > > surprise! - I didn't

> > > and my bite has relapsed over the years. I have my first surgery

> > > consultation this

> > > Wednesday with a Dr.Roser at the Emory Orthognathics Dept in

> Atlanta. I'm

> > > nervous but

> > > also a little be excited....I've known for a long time that I

> needed to

> > > have surgery

> > > again and finally feel ready to go through the process all over

> again.

> > >

> > > My biggest concern right now is with insurance coverage. My

> first surgery

> > > was not

> > > covered (even after many appeals) and it cost over $50K! (I

> almost died

> > > when my mother

> > > told me how much it had all cost) From what I've been reading it

> seems

> > > like the prices

> > > have come down but I'm still terrified at the idea of paying for

> this out

> > > of pocket. I have

> > > United Healthcare and have been looking through my booklet on

> their

> > > exclusions and

> > > included services - in one section it says any orthgnathics

> procedure is

> > > not covered but

> > > then somewhere else it says that treatment for TMJ would be

> covered. I

> > > don't really have a

> > > lot of jaw pain (TMJ) but I wondered - how willing are surgeons

> to help

> > > you out with

> > > submitting something under a certain code, even if that code

> does not

> > > necessarily best fit

> > > your problem? I'm just wondering if there is a way to approach

> this with

> > > the insurance

> > > company that would make it more likely to be accepted?

> > >

> > > If anyone has any advice on insurance codes or working with

> United

> > > Healthcare I would

> > > greatly appreciate it!

> > >

> > > Thanks!

> > > W.

> > >

> > >

> > >

> > >

> > >

> > >

[Guest guest]

Hi Clare,

I am glad you are so well prepared. Having all the information you

have, have you contacted your state insurance commissioner about

this? I live in Washington state, and our commissioner is fabulous

about assisting in cases like this, when the patient has ample

evidence of appropriateness and coverage eligibility and has been

repeatedly denied. With your Dad being an attorney, I am sure he

can make the case to the commissioner. Sometimes that gets the ball

moving a lot faster.

In any case, I am hoping the easier route will be that you are

approved tomorrow. Will cross my fingers for you and watch for your

post! Good luck!

Hugs,

Fran

> > > >

> > > > Hello! I'm new here and just wanted to say what a huge help

this

> > > > site has been so far. I'm 29 years old and am getting ready

to

> > have

> > > > jaw surgery for the 2nd time. I had a fairly severe

underbite and

> > > > crossbite as a child

> > > > and had surgery for it when I was 14 years old. It was a

pretty

> > rough

> > > > experience but I'm

> > > > glad I did it. The orthodontist that I've been seeing was

> > schocked that I

> > > > had the

> > > > surgery so young. My surgeon thought that I had quit growing

> > but -

> > > > surprise! - I didn't

> > > > and my bite has relapsed over the years. I have my first

surgery

> > > > consultation this

> > > > Wednesday with a Dr.Roser at the Emory Orthognathics Dept in

> > Atlanta. I'm

> > > > nervous but

> > > > also a little be excited....I've known for a long time that I

> > needed to

> > > > have surgery

> > > > again and finally feel ready to go through the process all

over

> > again.

> > > >

> > > > My biggest concern right now is with insurance coverage. My

> > first surgery

> > > > was not

> > > > covered (even after many appeals) and it cost over $50K! (I

> > almost died

> > > > when my mother

> > > > told me how much it had all cost) From what I've been

reading it

> > seems

> > > > like the prices

> > > > have come down but I'm still terrified at the idea of paying

for

> > this out

> > > > of pocket. I have

> > > > United Healthcare and have been looking through my booklet on

> > their

> > > > exclusions and

> > > > included services - in one section it says any orthgnathics

> > procedure is

> > > > not covered but

> > > > then somewhere else it says that treatment for TMJ would be

> > covered. I

> > > > don't really have a

> > > > lot of jaw pain (TMJ) but I wondered - how willing are

surgeons

> > to help

> > > > you out with

> > > > submitting something under a certain code, even if that code

> > does not

> > > > necessarily best fit

> > > > your problem? I'm just wondering if there is a way to

approach

> > this with

> > > > the insurance

> > > > company that would make it more likely to be accepted?

> > > >

> > > > If anyone has any advice on insurance codes or working with

> > United

> > > > Healthcare I would

> > > > greatly appreciate it!

> > > >

> > > > Thanks!

> > > > W.

> > > >

> > > >

> > > >

> > > >

> > > >

> > > >