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1. • CommentAuthorLesterAnne
   • CommentTimeOct 8th 2009

    
   Hello All:
   
   I am brand spanking new to this board. I am 27 and was told I have a recessive jaw and this surgery was required to fix it. When my orthodontist told me this, suddenly, a good deal made sense (headaches, TMJ, lisp, difficulty speaking, difficulty chewing my food or biting in to food, troubles sealing my lips, cracked bottom teeth and the like, even though my teeth cosmetically look fine.)
   
   After months of debate I have decided to begin the process. Thus, I have landed at the big insurance question.
   
   I'm in Northern Virginia but work in DC, thus my insurance -- Carefirst Blue Cross/Blue Shield -- is based in DC. Thus far I've only made one phone call to my insurance company to find out if they even cover this type of surgery only to be told I need the specific billing codes.
   
   From what I've read online Blue Cross tends to be rather ... "stingy" when it comes to this type of surgery. Has anyone else worked with Blue Cross, even if in another state to get this surgery approved and how long has the approval process taken? I've spoken with one person (they didn't have Blue Cross) whose insurer rescinded their approval for the surgery less than 48 hours before it was scheduled, and it was only through the help of a friend who happened to be a lawyer that the surgery went forward as planned. Please tell me this is the exception, not the rule!
   
   Thanks!
2. • CommentAuthordougz1
   • CommentTimeOct 9th 2009

    
   All insurance companies are stingy when it comes to this type of surgery. It's flat out expensive. The only way that I was approved is that I was diagnosed with obstructive sleep apnea. What you need to do is find an oral & maxillofacial surgeon in your area that is willing to work with your ortho. Have him/her work on the diagnostics and they will come up with the codes to submit to the insurance.
   
   Be prepared as it may take a while. I have been working on this project intensively for about 3.5 years now. Normally, you go through the insurance approval process, then start braces and work on those for about 12-18 months, then go back and get the surgery approved again, then have the surgery.
   
   I am/was an extremely difficult case - I made all of my docs sigh and shake their heads when I first started. I had teeth going in every different direction, a narrow pallete, OSA (mentioned above), and I'm onery to boot. Not to mention a couple of jobs/insurance changes along the way. Near the end of the month, I will have about 12 hour surgery to hopefully start the finishing up process.
3. • CommentAuthorLesterAnne
   • CommentTimeOct 9th 2009

    
   Thanks dougz1!
   
   I'm lucky in that it appears it is only my bottom jaw that will have to be moved forward, which is apparently the least expensive of the joyous jaw breaking surgeries. The numbers I've seen are still pretty painful, but not as bad as it *could* be.
   
   It sounds like this is going to be tough slugging with my insurance company.
   
   Can you, or anyone else, contrast the experience of going in network vs. out of network relative to cost and results?
   
   Thanks again!
4. • CommentAuthordougz1
   • CommentTimeOct 12th 2009

    
   LesterAnne,
   
   I would never go the out-of-network route unless my last name happens to be Gates or Rockefeller - and I have the bank account to back it up.
   
   Note: Remember that even going out-of-network requires insurance company *approval of the procedure* to see any type of covered benefit for it. Read your insurance documentation carefully and see if you can get your employer's HR representative to help you determine coverage with the insurance company.
   
   Going out of network means that you get to choose your own doctor which is good unless it comes down to thumbing through the phone book. Actually, I did that the first time (thumbed through the insurance company's physician list) and it worked rather well. I managed to choose a doctor that teaches part-time at Indiana University (I live near Indianapolis - GO COLTS!!!) and has a full-time practice. At the onset of this process, he removed several teeth including some that were rotting in my gums never having erupted. I took one Darvocet because he told me to - the rest was Ibuprofren.
   
   It was mildly unfortunate that I couldn't continue with this doc because he is not on my current insurance company's list. I had to choose another doc but fortunately in Indianapolis, OMFS is a relatively close-knit specialty and it seems like most of the docs know each other. The day I called doc1's office to tell them I had to go with doc2, they told me that doc1 just happened to be getting together with doc2's department for lunch that afternoon and that she would send my paperwork with doc1. Piece of cake transfer.
   
   Going out of network also means you pay significantly more. With my plan the deductibles/co-insurance/co-pays/etc/etc/etc are separate. If you had met all other requirements in a given year and were done paying and everything was in-network then (in December, lets say) go to an out-of-network doc for any reason, all bets, warranties, guarantees, etc are off and you start over for anything out-of-network. Those bills can be quite shocking and painful.
   
   If you don't have any OMFS doctors in your insurance plan within a particular distance, some insurance companies will let you go to another doc and pay it as if it were in-network. It's called a network gap exception and you have to ask for it - I don't think they are obligated to tell you. There is also a treatment gap exception too so be prepared to understand the difference and know which one you want. Typically, it is the network gap exception. You need to get it approved before you go - call the service number on the back of your card. You may be surprised - many of the docs on my list were either retired, not really specialists, university department heads (that don't have time for surgery), or have some other circumstance that keeps them out of the OR most of the time. You want someone with experience who does OMF surgery on a constant basis. The insurance company may send you a list of doctors that they prefer. If any of them are within range, you probably won't get a network gap exception so don't get too emotionally attached to a doc before the insurance company gives their blessing. I had to prove their list void if I wanted my choice of doc and that's when I found my current doc.
   
   The OMFS docs may have other financing options to help out if you have to go out of network. You can try negotiating with the doc and the hospital. I think most docs would rather see you treated at a slim margin if that's all you can afford than to go without treatment. The medical and social reprecussions later on in life will do more damage from no treatment than the couple of bucks negotiated either way will ever yield in an investment.
   
   As one method to cut costs, try a university dental school (look for the OMFS dept.). I'm going that route and my rapid palette expansion which was normally just over $17k was on sale for $3k - with help from the insurance with price negotiation. You may be able to negotiate something similar They did the surgery at Methodist Hospital (off-campus). The experience was overall very good and the palette did expand properly.
   
   October 28th is my scheduled surgery date. It will be approximately 12 hours for me but it will be well worth it. I expect that it will be a good experience and I don't think I'll miss anything critical to my care from letting the insurance company dictate some of the terms. Remember that until the anesthesia is administered, you can still back out (ok - that's cutting it a bit close). Just remember to ask plenty of questions - and hold the right person responsible for the answers.
   
   Doug.
5. • CommentAuthorpushead
   • CommentTimeOct 13th 2009

    
   It took 6 months for me to get approved the first time around. United Health Care is my insurer. My ortho recomended I get approved prior to bracing up. So I went to my surgeon he submitted every thing and the wait was on. In defence of the insurance company I think my doctors office had allot to do with the hold up. I only discovered this after the surgery when a few bills came my way. Any how once approved I was braced up for about a year. During that time my annual renewal came up at work. Nothing changed as far as my insurance except for the annual renewal. Since that had occured they said my approval was no longer valid and I had to have my doctor resubmit every thing. About two months later and many phone calls on my part to my doctors office and the insurance company I was finally approved again.
6. • CommentAuthorLesterAnne
   • CommentTimeOct 15th 2009

    
   Thank you, everyone, this has been really informative. It does, however, make me want to curl up in a corner with my recessive jaw and cry!
   
   Next insurance question, and I hope it's not too personal, but approximately how much, out of pocket did everyone wind up paying (excluding orthodontics.) I know that's kind of like asking "how long is a piece of string," as it all depends on type of procedure, insurance, the doctor, the complexity of the case and your location.
7. • CommentAuthorpushead
   • CommentTimeOct 16th 2009

    
   I am not sure where you are located but every policy I ever had in the U.S. tells you up front what your out of pocket maximum. I went with a HSA plan so I new I had to pay $2,000.00 in medical bills for the year. Once I paid that any medical claims I made where paid 100%.
8. • CommentAuthorLesterAnne
   • CommentTimeOct 17th 2009

    
   I'm in Northern Virginia, but my policy is based in DC. My insurance is Care First Blue Cross and they've been not at all forthcoming.
9. • CommentAuthorpushead
   • CommentTimeOct 19th 2009

    
   You should have received a large package of information when you signed up for your insurance plan at work. I am assuming you got it through work. If you cant find it you should have a contact number for the agent/broker that provides your healthcare benefits. If you cant find that contact your HR department and find out who it is. This is all assuming you are insured through your employer.
10. • CommentAuthorznthomps
    • CommentTimeNov 17th 2009

     
    I was told the most important things was to have an experienced and savvy surgeon write a letter to request the procedure be covered by the insurance company. So, my surgeon wrote a very detailed letter about how in his expert medical opinion, surgery was medically necessary for me. Blue Cross approved it on the first try (took about 10-14 days).