After 8 months of working on the issue of getting the wisdom teeth out and the jaw work done simultaneously by an out of network doctor who is highly regarded in his field, we threw up our hands in total frustration.
You may recall it started in December. Mel’s cartilage had migrated to the front of the jaw hinge. The specialist recommended arthocentesis and gave us an estimate for combining it with the wisdom teeth extraction. In December the matter would have been divided between Delta Dental for the teeth and Aetna HMO for the jaw. This is when we learned that Doc is not in the Aetna network. This required going to the primary care physician and getting a referral for the medical portion (even though the medical doc never had anything to do with it). After a couple of months and a zillion calls requiring intervention from the Aetna participator rep on the primary’s end we finally learned that it was up to me to search the list of participating specialists and find one in the network. After much more research I find only 1 in the entire metro area who does jaw work at all. He is 25.3 miles away in Chandler so I figure I am home free. I write in for the out of network approval. Well, it is denied ( the travel limit has somehow gone up from 25 miles to 30) which I learn after several more calls just two days before we leave on vacation.
I relent and make an appt with the network guy for the day after our return. This is time critical as college is starting in August, Mel is working and this is going to take some time. Well he does not want to treat the matter the same way, opting instead to do the extraction and try some splint therapy. And he was wrong on a number of things that Mel had just learned in anatomy class. Skeptical I call the regular dentist and he cautions that the original specialist knows what he is doing and if that were the efficacious route he would have recommended it himself.
So back to square one. I attempt to work out some kind of cash deal for the medical portion with the original specialist only to find that after January 1 Delta no longer covers wisdom teeth extractions if you have medical that will do it, the specialist’s rates have gone up and he forgot to include the estimate for the splint follow up on my document which is $1900. Now I would need to pay $4800 in advance and risk getting nothing reimbursed.
So now I am back on the insurance track again. I ask for a copy of the first denial, having never received it in the mail. Incredulous the Aetna phone person indicated I was out of luck-it was an electronic file and they could not make a copy. Now I have to get our HR department involved at work from whence the coverage emanates. Numerous conference calls later I finally get a hard copy of the letter faxed to me and now I know my appeal rights.
I appeal. I hear nothing until a couple of weeks later when I get a letter acknowledging receipt of my appeal. THE VERY NEXT DAY I get the denial. Now it seems that I have NO COVERAGE WHATSOEVER as TMJ is excluded under the policy under every circumstance. If only I had known that in first place. We consulted the policy’s fine print regarding the wisdom teeth but it never occurred to us that the jaw issue would not be covered.
We gave up. Mel got her teeth cleaned as the 6 months had elapsed between regular cleaing appointments. It was a bit challenging to hold her mouth open. But generally she is not in any immediate pain and her mouth limitations are bearable. Our new plan is to wait for open enrollment, change plans (I will never do the HMO thing again, EVER--something I had sworn off in the past but thought that Aetna would be a better deal than that old program, but, no, they are too busy spending $358 million buying a local insurance agency to pay for my piddling claims) and up the flexible spending account to cover what will be left. Of course that may be the whole thing as it will no doubt be considered a preexisting condition and declined even if we can find a jaw policy.
So I let it go.
Then the miracle. Seems Mel was jumping on a trampoline with her pal Ned and he bashed into her face (on accident). She said it hurt like hell for about 3 hours but ever since her jaw seems to be in perfect alignment. We are now rushing to get her to a regular oral surgeon (½ mile from our house I might add–not 25.3 miles away in Chandler) who will take both insurances and work it out from there. How is that for turning lemons into lemonade? I figure if I billed my time this whole thing would require a second mortgage on my house.
THIS SYSTEM IS INSANE!!!! We have got to get the insurance companies out of the way. There is no relationship with your doctor anymore and that is the key to maintaining proper health. By delaying and arguing and faxing and appealing we add huge costs to the system, the most major of which is the lack of efficiency (here we would have had two procedures, two anaesthetics, etc) not to mention the increased cost associated with treating the worsening condition while time passes. INSURANCE companies add nothing of value to the system. The value they add is to their bottom line. This takes all of the market place decisions and moves them to a secondary market. This dilutes the value of information necessary for making a sound economic decision in the market place. This is not capitalism-it is an aberration
I have noted before that the problem with capitalism and the environment is that it is impossible to put a market value on the air/water, etc.(this carbon trading thing is simply a bunch of hoo haw). Well we have the same problem in the health care industry. The cost of maneuvering the system, which is often borne by a coopted family member is never captured. Therefore the measurement is seriously distorted. If my time were quantified and added to the mix in this fiasco along the actual cost would probably boggle the mind and make it simply a bad way to go financially.
We need to get to the private health care account model as soon as possible (unless someone can come up with a better idea in the meanwhile). At least that would get the biggest impediment out of the way.
Now, I am really letting it go. I mean it this time.
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