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My 10 year old son was injured in an accident triggering my medical insurance. His injuries included substantial damage and displacement of his adult teeth. Now, a year and substantial oral surgery later he needs braces to pull his teeth into alignment and close gaps. Oral surgery claims covered by medical insurer with no problem (90% of 100% of approved rate).

Insurer does not have orthodontists so I get ours approved to be covered at in-network benefit. Pre-submit expense for precertification so no surprises even though not required. Receive response they will pay 90% of 50% because they have no basis for an approved rate for services. When I investigate they tell me to appeal. When I appeal I am told I have to wait to appeal until service provided, they pay the claim (90% of 50%) and my orthodontist bills me for remaining balance.

I am now at that stage, writing appeal. To help me compose a compelling appeal, I'm wondering if anyone has an idea of the logic for the 50% part of the equation? How can they justify any figure other than 100%? Dont get me wrong, I get why they would rather pay out less but how can they justify doing it?

Am I missing something? Thoughts appreciated!

Mod: this situations involves thousands of dollars so finance seemed the right place to post. Please move if not. Thanks.

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did he try to eat a M80?? for petes sake!!

OIiverQuackenbush (Jun. 02, 2013 @ 7:54p) |

That's great!

Thanks for returning to your thread and completing the story - so many folks don't do that.

NantucketSunrise (Jun. 02, 2013 @ 9:49p) |

To those with enduring curiosity about the cause of his injury, The injury was sustained from a fall from a ski lift to ... (more)

rblakenyc (Jun. 03, 2013 @ 8:35a) |

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If it is in-network and approved they should have to accept whatever the insurance company is willing to pay(and your copay). If the in-network doctor and insurance company have not agreed on a rate for this service that should be between them. I would wait till you get a bill and see what they are trying to charge you. They may only end up charging you 10% of half the normal rate. If they charge you more then your appeal should point out you this is a in-network provider and you only need to pay 10% of the final charge. Either the insurance needs to pay more or the doctor needs to write it off.

Edit: Just read it more closely. Looks like he is not actually in-network, and your insurance company only wants to pay the in-network benefit amount. In that case I would argue since there are NO in-network providers for this service at all, in good faith, they should pay the full amount, minus your copay. Alternatively, explain this is to the doctor and try and work out a discount for the rest.

What kind of accident ? sports , car etc? isn't the person responsible for the accident having their insurer pay you? Or is there no at fault party ?

find an at fault party and make their insurer pay 100% of the med bills. Yes this may include a school or friends parents homeowner policy

If they actually said they offering to pay 90% of 50% you could always just ask him to give your son the VIP package that includes a balloon and charge you double. Then write off the rest of course. Kidding of course, as that would be insurance fraud. Just pointing out how odd it is they just want to pay a flat half to whatever he charges.

To clarify, and as your edit surmises, the orthodontist and medical insurer have no enduring relationship. The paperwork to have him treated as in-network did not obligate him to accept a certain rate and the insurer hasn't attempted to negotiate nor even has a basis for negotiation as they have no in-network rates for orthodontics.

It is odd that they pick a flat 50% of what the orthodontist quotes. I was tempted to get the service that included a very expensive balloon but that wouldn't have worked or been legal. I did try to use the situation to get a discount but that didn't fly.

Also, the accident really was his own fault or at least enough so that not worth taking anyone to court.

I will certainly argue that they promised 90% of what it a medical bill was going to cost me when covered but I am puzzled that they seem to think that i should simply accept their policy of paying based on 50%. They act like I am crazy to question them on how they come up with or justify that!

We are talking more than a few thousand here so worth at least some fighting!

I'm reading this as this Insurer does not have orthodontists because your insurance doesn't normally cover orthodontist's procedures. I understand that your son is special case being injured in a accident. But their job end when the mouth is repaired and functional. They don't owe your son perfectly straight teeth. I think the insurance company is being generous of they pay any more than 80%.

Do you have separate dental insurance? Can you go through them to get their in-network insurance rates --- they may not pay the bill but at least apply the in-network rate. Then have the (discounted) bills reimbursed through your medical. They should reimburse that at 90% of the in-network rate.

Thanks for the thoughts and ideas. Dental coverage doesn't cover orthodontics in any meaningful amounts - and in my experience simply cap the amount at a nominal contribution without establishing a fair rate. I did explore this to find out what our orthodontist charges when it is dental insurance and he said they do not have negotiated rates.

Do178b, this is a fair point and was curious if that was their logic. I will say his upper teeth are broken and twisted in a manner you would find hard to imagine - so the treatment isn't really about cosmetic repair it is about health. I doubt he will end up with a pretty mouth and we will probably be paying for implants that are not covered. Interestingly, they do not seem to be making the case that 50% covers the medical necessity and the rest is cosmetic. At least at this point.

I can't believe that kids don't experience medically related dental claims with sufficient frequency that they haven't worked this out. They do clearly state that they cover orthodontics in his situation with no mention of the rates or lower percentages.

Goodness - your poor son - it sounds really traumatic and painful for him.

I don't know much about insurance, so the following idea might not be possible for you, but there have been several threads here in the past few months that talked about asking for the cash rate from a health provider, because often it's much, much cheaper than any rate the provider would charge an insurance company, and often the whole "cash" charge is cheaper than the deductible and co-pay that the insured party would have been charged by the insurance company. Apparently, after you pay a cash rate, you can get a particular type of detailed statement and receipt for the medical procedure and cash transaction, and still turn those in to your insurance company, if there is any reason why that would be advantageous (to have them apply it towards your plan's annual deductible, for example, if they would allow that). There are several online newspaper articles (one was in the L.A. Times, I recall) and internet sites (one is by a practicing M.D. who is fed up with our country's insurance system) about doing this.

--
Oops, I've re-read your OP and it seems they told you to have the work done by the provider and then lodge an appeal, so if you agreed to that and are at the appeal-writing stage, I guess the paying-cash idea is not possible now.

Maybe they consider it cosmetic. try to find a "medical" reason for the braces... such as jaw pain or TMJ. Possible the medical side of insurance might pick up the expense.

This wasn't a car accident, was it?
Is car insurance secondary with medical insurance primary?
Then shouldn't car insurance pick up the difference?

Or maybe the sort of accident your homeowners would cover?

rblakenyc said:   Also, the accident really was his own fault or at least enough so that not worth taking anyone to court.As much as I hate to say it, there must be some deep pocket that is at least partly to blame. You might really want to talk to someone with personal injury claim experience.

OP,

How this plays out may depend a little on what state you are in.

In addition to filing an appeal, I would file a complaint with your state's department of insurance regulation (or equivalent title, they vary by state).

In your appeal and complaint, make sure you include a copy of the approval for use of an out of network provider. I would go back and read that approval document very carefully to see what it says about benefit level.

You won't find what you need here, but rather you need to start searching to see what the law says in your state. Your state may have a law that is clear on the matter and provides a better framework for how to write your appeal/complaint letter.

Go back and find your plan summary document. Find the section that addresses use of out of network providers when an in network provider is unavailable. There should be a section and it should address the process and benefit level. This could also be used as a reference in your complaint/appeal letter.

I have not had to deal with this situation before, so I am merely outlining the strategy I would use to begin dealing with it.

I am going to guess that the term the insurance is going to use is "reasonable charges" and they may argue that the orthodontist's charges were unreasonable. If your approval specifically identified the provider you used, you have a good chance to compel the insurance company to cover the full amount billed (minus copays or deductibles).

In the meantime, you may want to actually review the claims submitted with the orthodontist. Make sure they used accurate diagnostic codes on the claims (as opposed to the most common codes they may default to).

Good Luck.

It's common for dental insurance plans to only cover 50% of services after meeting the deductible. That's the way mine is, although routine preventive care and diagnostics are covered 100% without a deductible. Maybe that's where they're getting the 50% from?

BocephusSTL said:   It's common for dental insurance plans to only cover 50% of services after meeting the deductible. That's the way mine is, although routine preventive care and diagnostics are covered 100% without a deductible. Maybe that's where they're getting the 50% from?

OP said that this is a medical insurance claim stemming from an accident. This is not a dental claim. This is essentially restoration, not cosmetic.

gatzdon said:   BocephusSTL said:   It's common for dental insurance plans to only cover 50% of services after meeting the deductible. That's the way mine is, although routine preventive care and diagnostics are covered 100% without a deductible. Maybe that's where they're getting the 50% from?

OP said that this is a medical insurance claim stemming from an accident. This is not a dental claim. This is essentially restoration, not cosmetic.

I know he said it's a medical insurance claim. He wants to know why they will only pay 90% of 50% of the orthodontics charges. I am suggesting that 50% may be a common dental insurance payout level, and since his insurer doesn't handle dental perhaps they are just using an industry standard of 50% as the basis for their payout.

And we're suggesting that OP should be pursuing it as an accident claim from the other party. Not as a medical or dental claim

ellory said:   And we're suggesting that OP should be pursuing it as an accident claim from the other party. Not as a medical or dental claim

Except it sound like OP's son was the cause of the accident...

To bring this to conclusion: I needed to file an appeal after the work was completed. I did and they approved the appeal! I got my full 90% after deductable - worth fighting for the $3,400
!

did he try to eat a M80?? for petes sake!!

rblakenyc said:   To bring this to conclusion: I needed to file an appeal after the work was completed. I did and they approved the appeal! I got my full 90% after deductable - worth fighting for the $3,400!


That's great!

Thanks for returning to your thread and completing the story - so many folks don't do that.

To those with enduring curiosity about the cause of his injury, The injury was sustained from a fall from a ski lift to hard frozen ground and rocks. Thankfully a helmet protected his head but his jaw and teeth absorbed a tremendous blow. It is unclear exactly what happened regarding the lift bar but it appears the lift had stopped somewhat near the instructions to lift the bar and he and his companion were sitting there for at least a few moments with the bar up when he fell. Happily, he is well on his way to recovery and now the latest insurance expense is covered. Hopefully he will not require implants for his lost and broken teeth as i do not think those are covered.



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