Approximately 6 weeks ago, our insurance company denied J's orthodontic work. She needs braces to move a tooth out of the way, because it blocking another tooth, which is, apparently, rotting in her gums right this very minute. Because it should have come down EIGHTEEN MONTHS ago, but did not, due to the other, blocking tooth. Because the braces are medically necessary, the orthodontist felt that insurance would cover it as a medical treatment, rather than an (uncovered) orthodontic one.

As I complained about 6 weeks ago, the claim was denied. The reason being that the administrator at the dentist's office somehow submitted the claim under E's name. Which was dumb. Because E's never been there.

I left angry voice mail messages, and after the weekend received a call saying that they'd resubmitted the paperwork under the proper child's name. There was little else to be done at that point, b/c J was 1/2 out the door to X's house in the Middle of the Country. I assumed this meant that things would get approved (or not, but at least on the substance of the claim, and not because of administrative ineptitude) while she was gone, and we could get it taken care of upon her arrival back home.

Today, I went and picked up our mail from the post office that had been held during our trip to Europe.

Guess what was in it?

A denial. From the insurance company.

Guess why?

Administrative ineptitude. Not under E's name this time - just some other fuck up with the paperwork.

I didn't get as angry as last time.

I also just don't know what to do. This cannot be something that I have to just accept. We first went to the dentist in February to get this issue taken care of. The x-rays showed a clear problem. This is not a cosmetic issue. This is a question of her tooth being trapped in the gum, and potentially breaking down. An adult tooth. Her fucking FRONT tooth. The orthodontist and the dentist both were struck by the unusual nature of the problem, and both talked about how we would take care of it "right away" - but b/c of administrative and insurance screw ups, it's 6 months later, and we don't even have an appointment set up.

I have made phone calls attempting to go up the chain both with the administrative department, and with the orthodontist himself. I am going to see if contacting the orthodontist directly (which I would have done in June, if J wasn't on her way out of town for 5 weeks) will work get a fire lit under the admin people faster. OR - if I can work out an alternative payment plan.

I'll pay for the braces myself. I don't care. I need it taken care of. But without talking directly to the orthodontist, the office won't let me do that. They say it needs to run its course. The course they keep fucking with.

My other option is to just go to another dentist, and that's very appealing. Since this one has so royally screwed up twice.

But there are insurance issues. I have new insurance as of 9/24, and I'm afraid to switch this close to the insurance change over. If I go to another dentist, planning to just pay out of pocket, will my new insurance cover it once the change over happens? Or will it be a 'pre-existing condition' that won't be grandfathered in?

I also am worried, b/c it's likely that she'll need surgery. I can't pay for surgery out of pocket. Braces I can, and most people do. But not surgery. If I go to a new dentist, and it turns out that surgery is now immediately necessary, I can't do it - and if it's seen as a pre-existing condition once new insurance starts up - then maybe it won't ever be covered?

This is why, despite my anger and their ineptitude, I am trying to force the issue with the current dentist, where the x-rays and the chart and the file and the info already exists. I want to make this happen sooner, rather than later. If she needs braces, and possibly surgery, I'd rather it happen before I start work in 6 weeks. If I have to start anew with a new provider, then it won't happen.

Woe is me. Woe is J. Woe is us.

Labels: *J*, anger, dentists

posted by Zuska @ 4:57 PM

2 Comments:

At Monday, August 13, 2007 8:42:00 PM, Anonymous said…

Have you tried getting help from your insurance ombudsman? Mine was great about being the go-between between the service provider and the insurance company. Basically made them both talk to each other rather than go through me. Insurance company tells the dentist, or in my case, optomotrist, what it needs EXACTLY to process your claim and how to code it so it is medically necessary not cosmetic and then hopefully the provider does so.
At Tuesday, August 14, 2007 8:09:00 PM, She says said…

Kinda off topic and totally late, but welcome back! It took me this long to read the posts, and it sounds like all is well in the world of Zuska. Yay!

And good luck with the orthodontist.