Just a quick question,
I was recently denied coverage for orthognathic surgery due to an exclusion. However, if I go ahead and pay for my surgery in full, am I automatically forfeiting my right to fight insurance? Will they be like, "oh, he already paid, why should we have to?" or something like that?
paying in full / fighting insurance
Moderator: bbsadmin
Re: paying in full / fighting insurance
I'm not 100% certain, but I don't think so.
The reason I think this is I was fully prepared to fight my insurance company tooth & nail. I may still have to, they approved it now but I will have to resubmit my predetermination before my surgery next year. Mine is also an exclusion from my insurance, but I was able to get the conditions for exclusion from my insurance, and my surgeon was able to address each condition in my letter of medical necessity-- mine required that you prove to have both a functional disability and a bone deformation. When I was talking to the financial/insurance coordinator at my surgeon's office, she said if any procedure with them was denied by insurance, I would pay a 25% deposit to the office and then they'd keep resubmitting the claim to my insurance company until we ran out of appeals. Then if the insurance came back as approved and overpaid, they'd reimburse me the deposit.
How soon is your surgery? I would say keep appealing so that they know you're not "done", and find out if you can do a partial pay to your surgeon just in case you get approved and will be reimbursed. Who knows how long the reimbursement process would take!
Good luck, hope you get coverage!
The reason I think this is I was fully prepared to fight my insurance company tooth & nail. I may still have to, they approved it now but I will have to resubmit my predetermination before my surgery next year. Mine is also an exclusion from my insurance, but I was able to get the conditions for exclusion from my insurance, and my surgeon was able to address each condition in my letter of medical necessity-- mine required that you prove to have both a functional disability and a bone deformation. When I was talking to the financial/insurance coordinator at my surgeon's office, she said if any procedure with them was denied by insurance, I would pay a 25% deposit to the office and then they'd keep resubmitting the claim to my insurance company until we ran out of appeals. Then if the insurance came back as approved and overpaid, they'd reimburse me the deposit.
How soon is your surgery? I would say keep appealing so that they know you're not "done", and find out if you can do a partial pay to your surgeon just in case you get approved and will be reimbursed. Who knows how long the reimbursement process would take!
Good luck, hope you get coverage!
Central Ossifying Fibroma removed from mandible 3/8/2012, braced 5/24/2012, One piece Le Fort I performed 12/11/2013, debraced 8/26/2014
Re: paying in full / fighting insurance
The answer is unfortunately, it depends. Each insurance carrier has different processes to handle exclusions and subsequent appeals. What has your insurance carrier told you concerning the appeals process? Also, many insurance companies have a time window whereby they must respond an appeal and so this should help yo uwith the planning portion of the 'do I or don't I' dilemma . . .
Typically, where appeals are concerned, the surgeon becomes the strongest advocate in terms of justifying the need for surgery as ultimately insurance carriers rely on the data that the surgeon provides rather than the emotional (and subjective) arguments of the insured individual. Essentially, engage the surgeon, and then follow-up every few days! Document everything and every conversation, it definitely will help your cause.
Good luck and keep us posted!
John
Double jaw surgery (18mm lower jaw, 12mm upper jaw widened, genioplasty)
doublejawoperation com
Typically, where appeals are concerned, the surgeon becomes the strongest advocate in terms of justifying the need for surgery as ultimately insurance carriers rely on the data that the surgeon provides rather than the emotional (and subjective) arguments of the insured individual. Essentially, engage the surgeon, and then follow-up every few days! Document everything and every conversation, it definitely will help your cause.
Good luck and keep us posted!
John
Double jaw surgery (18mm lower jaw, 12mm upper jaw widened, genioplasty)
doublejawoperation com