August 23, 2011 - the big day!
Just under three months away.
I called the insurance today and was finally able to make them see reason, so as much as you can preauthorize a surgery, mine's preauthorized! Yay!
Tuesday, May 31, 2011
Wednesday, May 18, 2011
The Call Before the Appeal
Getting jaw surgery covered by my health insurance plan has been no easy feat, but I've read online that this is pretty par for the course, so I just keep chugging along...
Yesterday, I got some good news when I just decided to go ahead and call the insurance company rather than waiting and sending in a letter. I thought it would be good to clarify the reason for denial. Well, did you know that when an insurance company is deciding whether or not to provide something, they probably don't even have a copy of your plan handy?
But once I gave her a copy of my plan and talked to her about the specific pages I was referencing, she said she "totally saw where [I was] coming from" and that they're going to call my surgeon to clarify under which category it belongs. Yay! Progress!
Jared's waiting to get excited until they actually say they're going to cover it, but I get excited and depressed with each new development in the insurance melodrama. The one good thing I can say about it is that it's kept my mind off the surgery itself, which I'm pretty sure I don't want to be thinking about too much.
Yesterday, I got some good news when I just decided to go ahead and call the insurance company rather than waiting and sending in a letter. I thought it would be good to clarify the reason for denial. Well, did you know that when an insurance company is deciding whether or not to provide something, they probably don't even have a copy of your plan handy?
But once I gave her a copy of my plan and talked to her about the specific pages I was referencing, she said she "totally saw where [I was] coming from" and that they're going to call my surgeon to clarify under which category it belongs. Yay! Progress!
Jared's waiting to get excited until they actually say they're going to cover it, but I get excited and depressed with each new development in the insurance melodrama. The one good thing I can say about it is that it's kept my mind off the surgery itself, which I'm pretty sure I don't want to be thinking about too much.
My Diagnosis and Procedure Codes
The world of medical jargon wouldn't be complete without some seemingly meaningless numbers that actually define the whole process for you!
Here are my diagnosis (ICD-9)codes:
524.03: Maxillary hypoplasia
524.04: Mandibular hypoplasia
715.98: Osteoarthrosis, unspecified whether generalized or localized
729.1: an acute, subacute, or chronic painful state of muscles, subcutaneous tissues, ligaments, tendons, or fasciae caused by a number of agents such as trauma, strain, occupation, exposure, posture, infection, or arthritis; Inflammation and fibrous degeneration of a muscle; A common nonarticular rheumatic condition that is characterized by muscle pain, tenderness, and stiffness.
Here are my procedure (CPT) codes:
21085: Impression and custom preparation; oral surgical splint
21147: Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)
21196: Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation
These are the codes that Dr. Voorhees has put in the information sent to the insurance company, although they, in my opinion, do not do the reasons behind the surgery or the surgery itself, any justice.
ERISA: seems good, actually bad
I learned that my health plan is ERISA (meaning that, probably like yours, it's employer-provided)
ERISA basically means that if you decide to sue the insurance company for breach of contract if they deny your claim, you are not allowed to sue for damages. Meaning that the most an insurance company has to lose if you take them to court is the cost of the surgery... so they're no worse off, minus attorney's fees, which you may or may not recover, and run about $40,000 for ERISA cases. Fun right?
Here's some information on ERISA:
ERISA basically means that if you decide to sue the insurance company for breach of contract if they deny your claim, you are not allowed to sue for damages. Meaning that the most an insurance company has to lose if you take them to court is the cost of the surgery... so they're no worse off, minus attorney's fees, which you may or may not recover, and run about $40,000 for ERISA cases. Fun right?
Here's some information on ERISA:
What does ERISA mean and how does it affect me?
ERISA is an acronym for a federal statute referred to as the Employee Retirement Income Security Act. This name is somewhat misleading because it sounds as though it only relates to “retirement income,” in fact, the act governs your entitlement to just about any employment related benefit, including retirement income, pensions, 401ks, disability benefits, group medical benefits, life insurance and death benefits and others. In addition, despite Congress seemingly passing a statute designed to protect the employee, the statute, in fact, does anything but that. The statute is a trap for the unwary and its provisions are slanted in favor of the employer or insurance company. It is an area of the law in which a person should seek legal representation.What Does Employee Retirement Income Security Act - ERISA Mean?
The Employee Retirement Income Security Act of 1974 (ERISA) protects the retirement assets of Americans by implementing rules that qualified plans must follow to ensure that plan fiduciaries do not misuse plan assets.
The Employee Retirement Income Security Act of 1974 (ERISA) protects the retirement assets of Americans by implementing rules that qualified plans must follow to ensure that plan fiduciaries do not misuse plan assets.
Investopedia explains Employee Retirement Income Security Act - ERISA
ERISA also:
1. Requires plans to provide participants with important information about plan features and funding. The plan must furnish some information regularly and automatically. Some of this information is available free of charge.
2. Sets minimum standards for participation, vesting, benefit accrual and funding. The law defines how long a person may be required to work before becoming eligible to participate in a plan, to accumulate benefits and to have a non-forfeitable right to those benefits. The law also establishes detailed funding rules that require plan sponsors to provide adequate funding for the plan.
3. Requires accountability of plan fiduciaries. ERISA generally defines a fiduciary as anyone who exercises discretionary authority or control over a plan's management or assets, including anyone who provides investment advice to the plan. Fiduciaries who do not follow the principles of conduct may be held responsible for restoring losses to the plan.
4. Gives participants the right to sue for benefits and breaches of fiduciary duty.
5. Guarantees payment of certain benefits if a defined plan is terminated through a federally chartered corporation, known as the Pension Benefit Guaranty Corporation.
6. Protects the plan from mismanagement and misuse of assets through its fiduciary provisions.
This act was enacted to address irregularities in the administration of certain large pension plans - particularly the Teamsters Pension Fund, which had a rather colorful history involving questionable loans to certain Las Vegas casinos.
ERISA also:
1. Requires plans to provide participants with important information about plan features and funding. The plan must furnish some information regularly and automatically. Some of this information is available free of charge.
2. Sets minimum standards for participation, vesting, benefit accrual and funding. The law defines how long a person may be required to work before becoming eligible to participate in a plan, to accumulate benefits and to have a non-forfeitable right to those benefits. The law also establishes detailed funding rules that require plan sponsors to provide adequate funding for the plan.
3. Requires accountability of plan fiduciaries. ERISA generally defines a fiduciary as anyone who exercises discretionary authority or control over a plan's management or assets, including anyone who provides investment advice to the plan. Fiduciaries who do not follow the principles of conduct may be held responsible for restoring losses to the plan.
4. Gives participants the right to sue for benefits and breaches of fiduciary duty.
5. Guarantees payment of certain benefits if a defined plan is terminated through a federally chartered corporation, known as the Pension Benefit Guaranty Corporation.
6. Protects the plan from mismanagement and misuse of assets through its fiduciary provisions.
This act was enacted to address irregularities in the administration of certain large pension plans - particularly the Teamsters Pension Fund, which had a rather colorful history involving questionable loans to certain Las Vegas casinos.
Tuesday, May 17, 2011
My Surgeon
May I introduce you to... my surgeon, Dr. Fred Voorhees, DDS, MSD. He's super nice and has a really calm demeanor, which is good for me, because I tend to get a little nervous...
Dr. Fred J. Voorhees received his Bachelor of Science degree from Trinity University in San Antonio and his Doctor of Dental Surgery from the Baylor College of Dentistry, where he graduated in 1977.
Dr. Voorhees conducted his residency in oral surgery at Baylor Medical Center from 1978-1982 and received his Master of Science in Dentistry in 1982. He joined our group in July, 1982.
He is certified by The American Board of Oral and Maxillofacial Surgery and his memberships include those in the American Association of Oral and Maxillofacial Surgeons, the American Dental Association, the Texas Dental Association, the Capital Area Dental Society, the Southwest Society of Oral and Maxillofacial Surgeons and the Texas Society of Oral and Maxillofacial Surgeons.
Dr. Voorhees conducted his residency in oral surgery at Baylor Medical Center from 1978-1982 and received his Master of Science in Dentistry in 1982. He joined our group in July, 1982.
He is certified by The American Board of Oral and Maxillofacial Surgery and his memberships include those in the American Association of Oral and Maxillofacial Surgeons, the American Dental Association, the Texas Dental Association, the Capital Area Dental Society, the Southwest Society of Oral and Maxillofacial Surgeons and the Texas Society of Oral and Maxillofacial Surgeons.
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