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Getting the Most From Health Insurance For Jaw Surgery

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!

13 Comments

  • Danny May 16, 2009 at 4:41 pm

    Hey Susan,

    Thanks for answering that question. And thanks for posing the question Liz.

    I’m re-visiting starting this orthodontist/orthognathic journey. I went to see an orthodonist when I was 17. He recommended that there was not much he could do as there was an abnormality to my jaw that needed to be corrected, in conjunction with braces. Back then the oral surgeon felt that I was young and that I should hold off a bit, just in case my jaw would continue to shift. Well, after 7 years, I decided to revisit the issue. Back then insurance was not the problem. However, now it is as I am employeed. I am currently with Healthnet HMO. The office manager who deals with insurance states that HMO plans will likely not cover the procedure. She said I have a better chance if I were to switch to a PPO plan. Her reasoning is that HMO plans funds are capitated to the medical group and they are likely to hold onto the capitation with minimal dispersal – meaning if orthognathics was to be approved, it has to be medically necessary. Whereas PPO plans, the funds are not dispersed, only when a procedure is done. I’m also assuming that this oral surgeon is not part of the healthnet umbrella/medical group that I am with.

    My frustration is that my job only allows me to switch health insurance once a year. So coming December, I have two choices to go with in hopes of getting coverage for my orthognathic surgery: 1. Healthnet PPO and 2. Kaiser HMO.

    If I choose to go with Healthnet PPO, then I’m assuming the office manager will do all she can to get pre-authorization for my surgery. I really hope the office will fight for me if I am denied the first time. I do not and cannot affort to pay out of pocket. My boss, who too had the surgery done with the same surgeon, paid 70K out of pocket. The downside is that I will have to pay a percentage of the whole fee; office manager said it will be $10,000-15,000 K.

    If I choose to go to Kaiser HMO, I have read many posts that they have a high approval rate and typically people only pay $500.00 for admission and $20.00 copays to see their surgeon. I’m from the bay area and have read that Oakland Kaiser has two well known oral surgerons who perform orthognathics.

    So I’m stuck deciding which route I would go with. Both I am unsure about the approval/pre-authorization process. If I can go the first route, I can choose the OS who is well known in the bay area. However, I would be looking at more financial burden. If I choose to go with Kaiser, there will be less financial debt, but I would be limited to two “well-known” surgeons that I have not met yet, and have only read about. I’m also stuck that I can only change health insurance once a year. If I choose one, and it doesn’t work, I’d have to wait another year to switch health insurance, and then re-attempt the surgey. For these reasons, I haven’t started braces yet.

  • Danny January 28, 2010 at 3:47 pm

    hey Susan,

    i am currently have similiar situation, a good candidate for this sufery. Do you know any sucesfual claim case for Healthnet PPO plan? If there is, how do we start doing research to find out which dr. is on the network. Appearnetly, most of oral surgents are out of the network. Please help!

  • susanfsu January 28, 2010 at 4:37 pm

    Hi Danny,

    Sounds like the best thing would be to invest 45 minutes into solving this and go ahead and call your insurance company. A few things to keep in mind:
    1. Always take detailed notes
    2. As the name of the agent you speak with, and be sure to get a record ## of your conversation
    3. Ask the important questions twice.

    Let me know how it goes!
    Susan

  • KC September 2, 2010 at 10:48 am

    Hi Susan,

    I’m new to your website…looks interesting! I’m wondering how your fight with the Cigna Open Access Plus PPO plan went? Did you have a hard time getting the approval?

    Thanks,
    KC

  • Rob November 27, 2010 at 1:06 am

    I have been diagnosed with sleep apnea about a year ago. Cigna gave me a CPAP machine which is basically a fan with a hose that I breath into at night. I cannot use the machine because it makes me choke. I explored dental devices that keep your mouth open so you can breath a night.
    These devices cost between 2,000 to 5,000. The one exam that i had the dentist said that my jaw was very out of place. He said the detnal device would work but if i wanted to fix it forever that the jaw needs to be pushed forward which would allow me to breath beter at night.
    I looked at the Cigna website and it does say that jaw surgery would be covered if the CPAP

  • Rob November 27, 2010 at 1:06 am

    I have been diagnosed with sleep apnea about a year ago. Cigna gave me a CPAP machine which is basically a fan with a hose that I breath into at night. I cannot use the machine because it makes me choke. I explored dental devices that keep your mouth open so you can breath a night.
    These devices cost between 2,000 to 5,000. The one exam that i had the dentist said that my jaw was very out of place. He said the detnal device would work but if i wanted to fix it forever that the jaw needs to be pushed forward which would allow me to breath beter at night.
    I looked at the Cigna website and it does say that jaw surgery would be covered if the CPAP

  • Rob November 27, 2010 at 1:09 am

    Cont,,, I got cut off. cannot be tolerated. I am going to see a maxi surgeon next week for a second opion. Any pointers to approach Cigna with the jaw surgery. I think it runs between 5,000 to 7,000. Thanks for this website!

  • Anna October 30, 2011 at 11:39 pm

    Hello. I was wondering what symptoms must be present in order for the insurance to cover the jaw surgery? My loser teeth touch (cut into) my palate and I often have swelling and it makes my teeth hurt really bad too. My jaw hurts pretty bad fairly often, but not continuously. Do these seem like symptoms insurance providers would allow coverage for?

    Thank you.

  • Kj January 3, 2012 at 8:38 pm

    Hi Susan. i read your blog and found it very helpful. I needed information on braces, jaw surgery and rhinoplasty. I need jaw surgery and rhinoplasty for my sever breathing problems and possible TMJD. Do you think Blue Cross with cover it? I doubt it would. The PPO plans don’t seem to cover anything through my Dad’s Insurance. I REALLY need to get this done, it is already getting in the way of college. The stress level is too overwhelming. If I switch to Kaiser HMO, how much would be covered? Also, do you think could get anything out of Medi-Cal? Thank You for your Response.

  • Chin March 22, 2012 at 6:14 pm

    I am faced with this dilemma and I want to know if there’s anyone out there who has dealt with Cigna before. I have the Open Access Plus PPO..and if anyone has tips on approaching Cigna it would be greatly appreciated.

  • DANIELLE March 20, 2013 at 2:13 pm

    I feel the same way. I have cigna. I need to review their exclusions. If anyone has any new updates, please let us know. Thanks.

  • Jameka May 12, 2013 at 3:47 am

    Hi Susan,

    It seems that I am having the same issue with Cigna. My employer benefits plan excluded maxillofacial surgery from our plan regardless of medical benefits. So when the request went to Cigna, it was automatically denied because my employer excludes it. So I called Cigna on multiple occasions and I was told that the the procedure is acutally one that they cover. My issue seems to be more with my employer than the insurance company. But now my employer is making me file an appeals claim with Cigna which does not make any sense to me.

  • Jorge Juarez July 4, 2013 at 8:04 pm

    I have a question. I need a insurance to covered me for a jaw and a bone graft surgery . I’m 37yo male and I really need some help and where or how to get the best ensurance that could covered for those surgeries. Anyone know?

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