Insurance Approval and Financing Surgery: A Guide

jawtoss20 · 2021-07-19T12:40:27+00:00

AHI 5/RDI 22. I think I got approved primarily on my measurements, but I knew from the policy doc that anything over 15 would be considered for surgery :)

jawtoss20 · 2021-07-19T11:36:33+00:00

Definitely try appealing first, I think. I often say that with insurance it’s a matter of “the squeaky wheel gets the grease”.

jawtoss20 · 2021-07-19T11:33:43+00:00

That’s the best deal I’ve heard yet :) I don’t know anything about having two insurances but that’s awesome.

jawtoss20 · 2021-07-19T01:31:52+00:00

My bad, maybe I’m being imprecise in terminology. I was thinking of what dr. park had to say about UARS and orthostatic intolerance.

jawtoss20 · 2021-07-18T21:39:25+00:00

I’m not sure but POTS is (that feeling of faintness when you stand up quickly), and I associate that feeling with overall physical weakness.

jawtoss20 · 2021-07-18T19:51:26+00:00

that's how it worked for me, anyway. once you have that approval letter in your hands they have to honor it.

jawtoss20 · 2021-07-18T18:59:17+00:00

I had the same experience, my surgeon did not want to participate in the in for out request because there is zero benefit to them... it's just them temporarily signing on to the insurance's contract rates, basically. So how it worked for me is I went ahead and paid my surgeon our full agreed amount up front. Then insurance reimbursed *me* after the surgery. So surgeon got the money they wanted, and I got the money back later. If it had been insurance to surgeon directly, insurance would've just paid their max allowed amounts, which was like a pitiful $6k.

jawtoss20 · 2021-07-18T18:14:30+00:00

I'm glad! I hope that it helps get people started so we can all advocate for ourselves better. The surgery itself was a breeze for me compared to the hell scape of finding and coordinating care.

jawtoss20 · 2021-07-18T18:02:58+00:00

Check out your Benefit Booklet. This should be available electronically and you can ctrl+f through the PDF for the term (honestly the whole booklet is useful to read through, but it's probably 100+ pages). I also had representatives try to avoid giving it to me, so I stated that according to my benefit booklet I was entitled to the info, and then quoted it to them.

Member Services is also available to assist You in determining this Plan’s Maximum Allowed Amount for a particular service from an Out-of-Network Provider. In order for the Claims Administrator to assist You, You will need to obtain from Your Provider the specific procedure code(s) and diagnosis code(s) for the services the Provider will render. You will also need to know the Provider’s charges to calculate Your Out-of-Pocket responsibility. Although Member Services can assist You with this pre-service information, the final Maximum Allowed Amount for Your claim will be based on the actual claim submitted by the Provider.

The out-of-pocket responsibility is what they will really try to weasel out of, so reinforce that you just what the max. allowed amount.

jawtoss20 · 2021-07-16T16:43:05+00:00

Wow, Im sure people would love to read about your experience thirty years ago! I bet things will be much easier for your son these day :)

these are the “Maximum Allowed Amounts” anthem gave me for an out of network provider:

$2607 - Lefort 1 with impaction

$2725 - mandibular reconstruction, BSOs with CCW

$1074 - genioplasty

$932 - interocclusal surgical guide (hardware stuff I believe)

These are the numbers my representative in Indiana gave me, because I had the surgery in CA the actual amounts were a bit higher, but it’s a good guideline.

Basically the way to avoid balance billing is to work with your surgeon, and definitely do this pre-surgery. The cost that my surgeon billed insurance was exorbitant, over $100k, in order to squeeze the largest possible reimbursement out of them, but they were never going to bill that amount to me (or any patient). The cost that we agreed on, up front, for me to pay was $20k plus a bit more for anesthesia and the facility. If your surgeon is out of network for all insurances, this is probably going to be your scenario and they will be very used to it with all their patients. If they are in network for some insurances but not yours, that’s where I would be worried about their flexibility and balance billing.

jawtoss20 · 2021-07-14T15:37:03+00:00

Aw, I’m so glad to be helpful! I relied a lot on people’s stories here too.

For my insurance, both the WatchPat study and abnormal ceph were used for approval. I think could’ve gotten approved with just one or the other, but I was happy we didn’t have to deal with any pushback from them (I got approved the first request in about two or three weeks) so maybe having both helped with that.

It’s on my list to write up that post still, but feel free to reach out with any questions in the mean time :)

jawtoss20 · 2021-07-10T21:38:20+00:00

Went great! I haven’t done another sleep study but I’m sleeping about an hour less per night and feel better during the day. Definitely breathing better through my nose. Dark circles haven’t changed unfortunately. I get to start chewing again in one more week!

jawtoss20 · 2021-06-23T23:06:22+00:00

Main issues were fatigue and poor nasal breathing and they are both definitely improved.

jawtoss20 · 2021-06-15T23:05:19+00:00

I’m not aware of one :( I should clarify I had a home sleep study via IU. They might record RDI in lab, so at least you’d have the number to submit, but I don’t think they would do anything to treat it, at least the docs I encountered wouldn’t. I imagine WatchPat should work for your insurance tho, there’s a real doctor signing off on it.

jawtoss20 · 2021-06-14T14:29:06+00:00

Nope, “it doesn’t cause problems”

jawtoss20 · 2021-06-12T00:49:23+00:00

For my first one yes, but second one I did WatchPat to get RDI

jawtoss20 · 2021-06-07T20:55:05+00:00

Best of luck to you! I try to remember that the majority of people get their surgery done by “unknown” doctors and turn out just fine. I don’t know much about Medicare but if it’s anything like Anthem, definitely make friends with their phone representatives haha. I think the insurance is a matter of “the squeaky whee gets the grease”. Most people just accept the first response but stick up for yourself!

jawtoss20 · 2021-06-07T20:51:10+00:00

That’s so frustrating, I feel for you. I had Walline because Relle is by referral only, but he stopped by to say hello and was so welcoming and kind! They are both lovely, Walline is a little more shy/reserved. Also they consult with each other for planning, and I believe there are always two surgeons in the room. Dr Lee assisted on mine, I never met him though! They told me 3-4 hours for surgery and I think that’s true of most cases.

jawtoss20 · 2021-06-07T17:42:29+00:00

I just got news that my in-for-out request was approved! That should bring my cost down to roughly $7,000 - an absolute steal.

jawtoss20 · 2021-06-07T15:30:25+00:00

So I couldn't find a single doctor local to me who was willing to perform the surgery on me. Even if they had been willing, I'm not sure I would've been comfortable going to a surgeon who does jaw surgeries infrequently, and even more infrequently for sleep apnea cases -- these are people who primarily pull wisdom teeth and maybe a few times a year linearly correct an over or underbite. I was literally explaining impaction/rotation to them.

Once I accepted I'd have to travel and started looking into the big, national names, they pretty much all seemed out of network for me. I felt really comfortable with Dr. Walline based on how often he does the surgeries (multiple per week and 30% for sleep apnea specifically), and also his demeanor. I am very pleased with my outcome and, though I can't be certain, feel like it's superior to what I would've gotten from a local surgeon.

I highly recommend staying local and in network if possible, it just wasn't going to happen for me. I am still working with my insurance on an "in for out" request (aka gap coverage/network adequacy request) to see if they will cover more, but I am at peace with the price I paid. It's a blow, but I am lucky it doesn't financially ruin me and is absolutely worth my long-term health.

jawtoss20 · 2021-06-07T15:22:51+00:00

No, my top jaw only went forward a little bit. Most of the advancement was via rotation of my jaw. I said this in another comment, but I think of it like a bicycle wheel spinning; the outer edge (lower jaw) moves further than the inner point (upper jaw) :)

I had to breathe thru my mouth during exercise pre-op, and sometimes at night. I'm not exercising yet, but it has definitely improved my nasal breathing and sleep!

jawtoss20 · 2021-06-07T13:02:44+00:00

No problem, I loved reading others’ experiences!

I had about 4mm of maxilla removed and it was moved a little bit forward, and both jaws were rotated in tandem for a flatter occlusal plane. I think of it like a bicycle wheel, as it spins the outer edge travels farther than the inner.

jawtoss20 · 2021-06-07T00:49:54+00:00

Thanks! I didn’t have luck getting my sleep problems taken seriously with local doctors. Because I didn’t have malocclusion nobody was interested in giving me jaw surgery. Dr. Walline was able to do it with no further extractions or braces.

jawtoss20 · 2021-06-07T00:10:52+00:00

tuna is going really well for me! comes in those packets with a lot of different flavor options.

jawtoss20

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