How do you deal with your health insurance provider to get maximum coverage for jaw surgery and adult braces?
This is one of the most common questions I get about corrective jaw surgery and adult braces for underbites, cross bites, and other bite misalignment.
Everyone’s situation is going to be unique. Still, there are a few things you can do to increase the likelihood that your health insurance provider will provide maximum coverage. This applies whether you’re on an HMO or a PPO health insurance plan.
What to Know About Health Insurance Companies (and How To Deal)
1. The person who answers the phone at the call center most likely has NO familiarity with your procedure or the insurance best practices surrounding it.
Keep this in mind when you’re spending minutes or even hours trying to explain to the call center rep that you really need this, your doctor said that, blah blah blah. His or her job is to answer the phone, search through databases for your ID number, and tell you the safest answer (for the company). By the way, the safest answer is usually “No.”
If you get the distinct sense theat your rep has misunderstood you, or told you “No” as a safety answer to get you off the phone, don’t blame the poor sap – it’s his job!
Instead, say “Ok” and get off the phone so you can immediately call again. You will most definitely be connected to another to a different person who may give you another answer.
The key is not to waste time arguing with insurance company reps on the phone. It will drain your energy and take your time away from more important insurance matters.
2. Not all insurance providers are equal.
Full-coverage HMO plans will often cover this procedure, but you will NOT get to choose your surgeon or even your orthodontist. Keep this in mind as you consider how your surgeon’s expertise and specialized skills in reconstructive jaw surgery will impact your results and recovery.
I once read a jaw surgery blog by a young man who also happened to work at my old company – Google – when I was there. Unlike me, on the Cigna Open Access Plus PPO plan, this young guy was on the Kaiser HMO plan.
For his surgery, he was assigned to a more or less general oral surgeon. This surgeon had no doubt performed the procedure before, but did not make his name as a world-reknowned specialist from reconstructive jaw surgery, the way my beloved Dr. Kasey Li has. My coworker had to go back for two surgeries – not as originally intended – and had a recovery that kept him on liquids for 6 weeks.
Horrible, horrible nightmare for those of us who love eating.
Finally, on this point, some insurance simply won’t cover this surgery at all. Aetna and Blue Cross are providers that other patients have struggled with.
Here, the strategy is to think ahead and make sure your healthcare provider covers this surgery at all. That question precludes any question about whether or not they’ll cover you.
3. Insurance companies respond to the experts.
I definitely had jaw pain and swelling from my years of having an underbite. This is apparent from my ‘Before’ photos.
However, it was not a life-threatening situation by any means.
In fact, I myself had a tough time justifying it to skeptical friends. How then, was I going to win a case before the much tougher audience of an insurance company medical director?
I wasn’t, and I’m glad I didn’t spend lots of time trying.
Instead, I let my surgeon’s office’s financial expert do the talking, for these reasons:
- They can explain the need and procedure MUCH better than me.
- They are in it for the money.
- They’re more likely to have useful connections from their years of working with insurance providers.
The caveat to this is that you need an excellent independent surgeon with an expert office staff. It’s doubtful that an HMO practitioner will have the time or resources to argue your case for you. Plus, since they basically work for the healthcare / insurance provider, it creates an unfortunate conflict of interest.
What are your experiences with insurance coverage? What works, what fails? Share in the Comments!