jawsurgeryforums.com
General Category => Functional Surgery Questions => Topic started by: OHjawz on March 21, 2017, 11:58:59 AM
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I'm looking into a double-jaw revision and have a consult scheduled with Arnett-Gunson out in Santa Barbara. The problem I am having is finding an insurance company and plan the would willing to work with the them or the hospital they use, Goleta Valley, to help cover facility fees at the very least. Is there an insurance or plan out there like that? Has anyone else run into this problem and found a solution? I live in OH
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I recommend that you contact their office to inquire about this. I think that they can send information about PPO's and the level of coverage that might typically be provided. My understanding is that an HMO will not work.
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I have already contacted their office. Their office gave me the info and transferred me over to their insurance lady. I got in contact with the insurance lady and she gave me some rough outlines but not too much as she was weary to talk insurances/plans and estimated coverage because she wasn't aware of what was available on the market in Ohio. She then told me to contact that Goleta Valley hospital to inquire about their in-network status with different companies/plans. The hospital told me to call the actual insurance company rather than them. I spend some time talking with an Anthem rep (as those seem to be the only PPO plans in the marketplace) but he was not really too helpful. He was nice, but I think he was in a little over his head with some of the specific questions I was asking. He sounded like he had been trained to help walk people through the website to help them sign up but not much more than that. I'll probably give them another call today to see if I can't get someone else who is a little more knowledgeable.
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I recommend identifying the specific PPO options that are available to you in Ohio. Then, it would make sense to determine which of these, if any, exclude orthognathic surgery coverage. The insurance companies should be able to provide you with a comprehensive document providing detailed information about the policy coverages. The staff member at Arnett Gunson should be able to provide you with information about their experience with different PPO brands (United, Anthem, etc.). I think that considerations might include easy of pre-approval, maximum covered amount for surgery, deductible amount, and copayment/coinsurance level. If you get this information, then you might assess which policy makes sense for you, given your overall health insurance needs.
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Just to note, PPOs often state that they cover "X"% for out of network providers. The problem is that they cover that % of what they consider a "fair market rate", which is often comically low. My insurance pays 70% of our of network costs. Well, I just got my reimbursement check......$1,500. They say that the fair rate for a Lefort 1 and BSSO is like $2,200, which is just absurd. I knew this going in, so it didn't come as a surprise, but make sure you get an idea of what they consider to be a fair rate or you might get caught with a much larger bill than expected. US healthcare is so screwed up, in case you didn't know.
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Just to note, PPOs often state that they cover "X"% for out of network providers. The problem is that they cover that % of what they consider a "fair market rate", which is often comically low. My insurance pays 70% of our of network costs. Well, I just got my reimbursement check......$1,500. They say that the fair rate for a Lefort 1 and BSSO is like $2,200, which is just absurd. I knew this going in, so it didn't come as a surprise, but make sure you get an idea of what they consider to be a fair rate or you might get caught with a much larger bill than expected. US healthcare is so screwed up, in case you didn't know.
That's a good point. The large majority of the benefit of insurance coverage for Arnett-Gunson may be related to hospitalization costs.
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That's a good point. The large majority of the benefit of insurance coverage for Arnett-Gunson may be related to hospitalization costs.
This is the case in Australia. Insurance covers all of the hospital fees and a fraction of the surgeon's fee.
Fwiw, Gunsons surgery fee is very high. His hospital is very cheap (as far as American hospitals go IMO). I never got quotes from Wolford, but AFAIK his surgical fee is reasonable, but the hospital fee is astronomical.
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Just to note, PPOs often state that they cover "X"% for out of network providers. The problem is that they cover that % of what they consider a "fair market rate", which is often comically low. My insurance pays 70% of our of network costs. Well, I just got my reimbursement check......$1,500. They say that the fair rate for a Lefort 1 and BSSO is like $2,200, which is just absurd. I knew this going in, so it didn't come as a surprise, but make sure you get an idea of what they consider to be a fair rate or you might get caught with a much larger bill than expected. US healthcare is so screwed up, in case you didn't know.
Thank you, I didn't know about the "fair market rate" thing. That seems like the most irritating clause they could think of. Looks like I've got to make a couple more calls to Arnett-Gunson's insurance lady and the actual prospective insurance company to get some literature on the specific plan I have been researching. It looks like it would be an Anthem plan as they seem to be the only PPO plans offered in OH on the marketplace. I've read former patients mention Anthem Blue Cross Blue Shield PPO plans on here before. Anyone have any experience with them?
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Every insurance policy has a different name for it too.
Generally if you get the procedure codes you can contact your insurance company and ask them what they will reimburse for out of network service. The codes I have for my procedures (verify these are correct. Gunson should be able to provide) are:
PROCEDURE CPT CODE
Maxillary LeFort I Osteotomy 21141
Bilateral Sagittal Split Osteotomies 21196
Anterior Mandibular Horizontal Osteotomy 21121
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It looks like there may be something with Anthem called "balance billing". Does that sound right? Or is that something else entirely? I plan on calling Anthem Mon with my list of questions
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Quick Update:
Looks like insurance coverage hinges on the surgery being deemed medically necessary (Anthem PPO). Insurance stands to go 1 of 3 ways:
1.) Deemed necessary and out of network benefits kick in w/ an out-of-network out-of-pocket maximum of $19,650 then the remainder is covered. You still run the risk of the facility balance billing you the difference between the paid amount and the billed amount. So $19,650+balance billed difference. I suppose a reputation check of Goleta Valley Cottage Hospital and their balance billing practices would be the next place to look.
2.) Deemed necessary and the hospital and anesthesiologist are deemed eligible for in-network benefits as both are participating providers with Anthem BCBS in California according to Arnett-Gunson's insurance lady
3.) Deemed not medically necessary, surgery falls under cosmetic and I believe nothing is then covered
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Many insurance websites will tell you when they consider orthognathic surgery medically necessary.
With my "cadillac" BCBS PPO plan, many people with cosmetic issues but not severe problems otherwise would probably not make the cut unless you your TMJ is symptomatic or your sleep apnea AHI score is 16+. I got scored 10, so guess I'm screwed...
For orthognathic surgery due to skeletal deformity, you need to prove failure to thrive, unable to eat/chew, malnutrition, and skeletal deformities above a threshold depending on the vector (eg anteriorposterior, vertical, etc.). For example, anteriorposterior overjet of 5mm+.
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Many insurance websites will tell you when they consider orthognathic surgery medically necessary.
With my "cadillac" BCBS PPO plan, many people with cosmetic issues but not severe problems otherwise would probably not make the cut unless you your TMJ is symptomatic or your sleep apnea AHI score is 16+. I got scored 10, so guess I'm screwed...
For orthognathic surgery due to skeletal deformity, you need to prove failure to thrive, unable to eat/chew, malnutrition, and skeletal deformities above a threshold depending on the vector (eg anteriorposterior, vertical, etc.). For example, anteriorposterior overjet of 5mm+.
My biggest problem is that the first guy over-rotated my upper jaw too far to the left. I get a cramped feeling like everything does not have enough room back there on that side. As well, instead of double jaw surgery (lower jaw is crooked), he tilted the upper jaw to match the cant of the lower jaw. Dumb idea. So what you end up with is and over-rotation, several mm cant in both jaws, and a misplacement of the midline by 3mm or 3 & a fraction of a mm more. I hope it would be deemed medically necessary. I'm not planning that way, but I hope so. The insurance lady at Arnett-Gunson seemed to help put my mind at ease a little bit by reassuring me that the have a good relationship with Anthem and have been applying to insurances for over 30 yrs. I hope I can get a better idea once I go in for a consult and they actually see my mouth in person.
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My biggest problem is that the first guy over-rotated my upper jaw too far to the left. I get a cramped feeling like everything does not have enough room back there on that side. As well, instead of double jaw surgery (lower jaw is crooked), he tilted the upper jaw to match the cant of the lower jaw. Dumb idea. So what you end up with is and over-rotation, several mm cant in both jaws, and a misplacement of the midline by 3mm or 3 & a fraction of a mm more. I hope it would be deemed medically necessary. I'm not planning that way, but I hope so. The insurance lady at Arnett-Gunson seemed to help put my mind at ease a little bit by reassuring me that the have a good relationship with Anthem and have been applying to insurances for over 30 yrs. I hope I can get a better idea once I go in for a consult and they actually see my mouth in person.
I had a little different experience with the insurance lady. It's still a conversation-in-progress, but whereas I don't think I fit medical necessity, she is saying she can get me in on OSA and, secondarily, bite/overjet issues. Neither of which fit BCBS's medical criteria in their explicitly stated policy, and my bite is only really misaligned when you tuck my jaw back into the condyles about ~2mm, which is unnatural for me. The kicker is they won't file an insurance predetermination until you commit to paying them the full cost of surgery, regardless of if you get insurance coverage. I'm sure that's common with out of network doctors, but this isn't just a 15k rhinoplasty. If insurance deems it cosmetic and you suffer collateral damage post op, insurance won't cover extra doctor repair bills either on the premise that it is a complication from a cosmetic procedure.
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I had a little different experience with the insurance lady. It's still a conversation-in-progress, but whereas I don't think I fit medical necessity, she is saying she can get me in on OSA and, secondarily, bite/overjet issues. Neither of which fit BCBS's medical criteria in their explicitly stated policy, and my bite is only really misaligned when you tuck my jaw back into the condyles about ~2mm, which is unnatural for me. The kicker is they won't file an insurance predetermination until you commit to paying them the full cost of surgery, regardless of if you get insurance coverage. I'm sure that's common with out of network doctors, but this isn't just a 15k rhinoplasty. If insurance deems it cosmetic and you suffer collateral damage post op, insurance won't cover extra doctor repair bills either on the premise that it is a complication from a cosmetic procedure.
I have an email in to their insurance lady asking about what you brought up with filing to insurance. Also, someone in a different post talked about getting a paper consult from Arnett-Gunson before you go out there. I'm gonna ask her about that too
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I had a little different experience with the insurance lady. It's still a conversation-in-progress, but whereas I don't think I fit medical necessity, she is saying she can get me in on OSA and, secondarily, bite/overjet issues. Neither of which fit BCBS's medical criteria in their explicitly stated policy, and my bite is only really misaligned when you tuck my jaw back into the condyles about ~2mm, which is unnatural for me. The kicker is they won't file an insurance predetermination until you commit to paying them the full cost of surgery, regardless of if you get insurance coverage. I'm sure that's common with out of network doctors, but this isn't just a 15k rhinoplasty. If insurance deems it cosmetic and you suffer collateral damage post op, insurance won't cover extra doctor repair bills either on the premise that it is a complication from a cosmetic procedure.
So I got my repsonse from Arnett-Gunson's insurance lady. Here's what she said:
"No that is not true. Pre-authorizations are submitted 4 to 6 months prior to surgery after a patient has had a consultation, is in braces and has a tentative surgery date we are working towards. We do collect the full surgeons fees 60 days prior to surgery. Claims will be submitted to insurance after the surgery (for approved procedures)."
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So I got my repsonse from Arnett-Gunson's insurance lady. Here's what she said:
"No that is not true. Pre-authorizations are submitted 4 to 6 months prior to surgery after a patient has had a consultation, is in braces and has a tentative surgery date we are working towards. We do collect the full surgeons fees 60 days prior to surgery. Claims will be submitted to insurance after the surgery (for approved procedures)."
Ok so this varies depending on your situation. In my case, where my bite is currently very well camouflaged/compensated, I will have to first set my teeth into a craptastic bite relationship ('decompensated') before a preauthorization is submitted to insurance. Makes sense to show your insurance a terrible bite, and not the one you currently have.
The potential pitfalls with that approach is if insurance decides, after significantly messing up your bite with decomp ortho work first, that there still isn't medical necessity for bimax. OR you somehow decide the costs are still too great for bimax, then you are left with braces on until they cause damage and are removed, or you remove them and live with a terrible bite that you just spent about 8-10 grand for. I think a good question, for every case, is how bad your bite and smile aesthetic will be 6-8 months into decomp orthodontics.
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My biggest problem is that the first guy over-rotated my upper jaw too far to the left. I get a cramped feeling like everything does not have enough room back there on that side. As well, instead of double jaw surgery (lower jaw is crooked), he tilted the upper jaw to match the cant of the lower jaw. Dumb idea. So what you end up with is and over-rotation, several mm cant in both jaws, and a misplacement of the midline by 3mm or 3 & a fraction of a mm more. I hope it would be deemed medically necessary. I'm not planning that way, but I hope so. The insurance lady at Arnett-Gunson seemed to help put my mind at ease a little bit by reassuring me that the have a good relationship with Anthem and have been applying to insurances for over 30 yrs. I hope I can get a better idea once I go in for a consult and they actually see my mouth in person.
Your plan won't be exactly this, but in my plan your situation would probably be accepted by insurance.
Transverse discrepancies:
Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms; or
Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth; OR
Asymmetries:
Anteroposterior, transverse or lateral asymmetries greater than 3 mm, with concomitant occlusal asymmetry.