Dr. Wolford (Texas) expects full payment before surgery

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ladyjenie
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Joined: Mon Jun 08, 2009 2:16 pm

Dr. Wolford (Texas) expects full payment before surgery

#1 Post by ladyjenie »

I am scheduled for jaw implant surgery, turbinate & uvula reduction in September with Dr. Wolford in Texas. I have Aetna and Medicare but Dr. W does not accept insurance assignments. My primary insurance has reduced Dr. Wolford's fees by the 'reasonable and customary' rule and my out-of-pocket now stands at $44,000 for him alone that has to be paid before the surgery. I am tired of haggling with Aetna and don't know how to get them to pay more. Medicare is another story, they don't pay a dime. Help?

PJ
Posts: 276
Joined: Sun Apr 12, 2009 6:21 pm

#2 Post by PJ »

Wow!! That dollar amount seems outrageous. I also had to pay upfront and while my insurance did cover it in the end, I still ended up paying $9000 out of pocket, as the surgeon didn't accept the reduction in charges. Anyway, I had Lefort 1 and BSSO and the total cost was around $15,000. The hospital cost was $34,000 for just one night (crazy!!) but insurance covered that 100%. I can't imagine why your surgeon's fee is so high.

I don't know your situation, but I would strongly suggest finding another surgeon, if possible--especially one that will accept the insurance.

ladyjenie
Posts: 35
Joined: Mon Jun 08, 2009 2:16 pm

#3 Post by ladyjenie »

Dr. Wolford's fees are non-negotiable and now stand at $56,000 plus other fees such as hospital admit, surgery models, splint, etc., which are extra. I have spent so much on my tmj issues over the last 20 years. I have had braces twice and 6 splints. How does a family recover from something as catastrophic as this? I would use another doctor if s(he) were within my area but being disabled doesn't allow me to travel across state for something so major. Doctor Wolford is 2 hours from my home so I am lucky to have him so close. I want to use him because of his expertise yet can't afford him. I'm just hoping I can get Aetna to adjust or tweak their R&C fees for additional help but don't see that happening.

PJ
Posts: 276
Joined: Sun Apr 12, 2009 6:21 pm

#4 Post by PJ »

I am so sorry. Have you explained your situation to the doctor's office--maybe they would be willing to reduce the fees? I am still flabbergasted at the cost. I thought $15,000 was a lot. I hope you can find someone to help you investigate all the possible options. Maybe even some sort of government grant? I wish you all the best.[/b]

bbsadmin
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#5 Post by bbsadmin »

I have two suggestions for you:

1. Speak to your state insurance commission to see if they can help prod your insurance company.

2. If your local paper has a consumer help reporter (Action Line, or something similar) contact the reporter and see if he can help you.

I'm sorry to hear that this doctor expects up-front payment of such an outrageously high amount. It makes you wonder how doctors can lose sight of their humanity when they pull this sort of stuff on people who can't afford it.
I'm the owner/admin of this site. Had ceramic uppers, metal lowers ~3 years in my early 40's. Now in Hawley retainers at night!

ladyjenie
Posts: 35
Joined: Mon Jun 08, 2009 2:16 pm

#6 Post by ladyjenie »

PJ, I have discussed the surgeon's fees with his office, I was told he does not negotiate with the patient nor insurance company. The doctor knows you will find a way to pay or go elsewhere.
BBS, thank you for suggesting the insurance commissioner, I will give it a try. Most likely I will have to file a claim against Aetna.
Thank you for having this site to empower those of us in these circumstances.

ladyjenie
Posts: 35
Joined: Mon Jun 08, 2009 2:16 pm

#7 Post by ladyjenie »

I contacted the Texas Insurance Commission about Aetna's 'R&C' reductions, they could not help. I was told the insurance commission does not have anything to do with setting health insurance allowable amounts thus it boils down to the outrageous fee the doctor is charging. I have spent months with no result and decided I should try to find another OS who charges appropriate fees. Anyone have suggestions for a reputable OS near the Dallas, TX area?

chicago29
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Location: Chicago Suburbs, IL

#8 Post by chicago29 »

That surgical fee seems outrageous. Jaw Implants are much more complicated than upper/lower jaw surgery, so I would expect it to be more, but that seems insanely high.

I understand your hesitancy to change surgeons at this point, but I urge you to look around. You are in the Dallas area, which from my understanding has some world class health care facilities. Perhaps you can look at Baylor University, as I've heard they have an outstanding medical program.

Best of luck to you, and don't give up.
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PJ
Posts: 276
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#9 Post by PJ »

Maybe it would be a good idea to put up a new post on the boards here, asking specifically about surgeons in Dallas in your subject line. Not everyone will be reading this particular post. Best of luck!

ladyjenie
Posts: 35
Joined: Mon Jun 08, 2009 2:16 pm

#10 Post by ladyjenie »

Chicago29, Dr. Wolford is at Baylor/Dallas and yes, Baylor has some great surgeons. I had spine surgery there in 2000.
I spoke with Aetna today and asked if they could provide me with an OS that could do the surgery for the amount they approved, I wanted to put the proof of burden on them. They could not and in fact they offered no other OS's in the DAL area as in-network providers. My husband's employer's HR man could not imagine how Aetna could pay such a low R&C rate when there were no other OS's to compare rates to. He has a company rep putting that very question to Aetna now. Both Aetna and the HR man said Dr. Wolford was notorious for excessively inflated charges because he knows he has the market for this area. He also has the expertise but sadly the insurance company doesn't recognize that.
PJ, yes, I will start a new post to ask for recommendations in the Dallas area. The Dallas/Ft. Worth area is large so surely there is another OS somewhere. Thanks for suggesting I start a new post!

jul
Posts: 20
Joined: Tue Jun 24, 2008 4:28 pm

dr wolford

#11 Post by jul »

ladyjenie - are you talking about having the joint replaced. Dr. Wolford does a lot of those. If you are - you can call TMJ concepts - the company who makes the joints - they will give you names of surgeons in Dallas who put in the joints. TMJ concepts has a website you can get the 800 number there.

chicago29
Posts: 734
Joined: Tue Jul 22, 2008 12:34 pm
Location: Chicago Suburbs, IL

#12 Post by chicago29 »

ladyjenie,

It really saddens me to read this. I have always suspected some doctors of taking advantage, but this is flat out ridiculous. I would think somebody that is so well respected (and likely has all the money in the world) would find some compassion for your situation.

My only advice is to do all you can to stick it to Aetna. I had a similar issue with my insurance (Anthem Blue Cross) in that there are no "in network" providers within 100 miles of me. Luckily I got an "out of network exception" so they will pay more than they would for an out of network provider, but it is still a far cry from the total fees I am being charged. My only saving grace is my surgeon is "only" charging about $33,000 for 2 surgeries (SARPE/MSDO and a LeFort I/BSSO).

Keep working with Aetna and hopefully you will get them to pay at a higher rate...Best of luck.
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ladyjenie
Posts: 35
Joined: Mon Jun 08, 2009 2:16 pm

#13 Post by ladyjenie »

jul, thank you for suggesting TMJ Concepts website, I will check it out although I doubt any OS is going to be in-network with Aetna because of the liability and costs involved for jaw implants. Dr. Wolford is charging $25,000 for the surgical part and the hospital will bill $14,500 for each TMJ Concepts prostheses + that's not even half the charges.
Chicago 29, I have appealed everything with Aetna I know to appeal. Other than taking this to a lawyer for interpretation I'm at a loss as what to do. I think the proof of burden should be on Aetna to pay at the higher rate if they don't have an OS in network that can do my surgery but Aetna has sent me a letter saying I'm responsible for co-insurance and R&C. I really thought since I had Aetna and Medicare I could afford the surgery but little did I know Wolford's office wants the money up front, regardless, and that amount stands at $38,000 now.

Braceschris
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Joined: Tue Feb 06, 2007 6:33 pm

#14 Post by Braceschris »

Sorry to here of all the problems that you are having. I hope that your husband company can talk with Atena and get it taken care of. I had a problem with UHC in regards to a Herbest Retainer that was being used for sleep apnea and not ortho. The dentist was out of network etc. It took me a year and 3 letters witht he last on going to my employeer and to the insurance commision. Within no time they paid it all in full. Have you talked with the Hosp. about reduce costs, maybe call the dental device company and see if they have a program to help pay for the device or reduce their cost. Also keep in mind that when you file your taxes for 2009 what ever you pay out of pocket after your 7.5% ded of the adjusted gross income you can take off on your taxes so you might get some money back that would help offset the high cost. I know everyone talks to office people/manger, but have you talk to the doctor himself about his charges and how it is not allowing you get get treatment from him. Also have you asked him for a referral to another doctor? Also do you have any medical flex spending account that you could use and reduce the taxes you have to pay? Also is there any goups that might have grants or something like that to help you with cost? Have you looked about some type of loan program or something like that? I wish you the best of luck, and if you need any help just ask. We are all here to help you out.

Chris

ladyjenie
Posts: 35
Joined: Mon Jun 08, 2009 2:16 pm

#15 Post by ladyjenie »

Chris -
I probably won't have as much trouble with Baylor/Dallas because they are in my husband's network but to contain my costs I will talk to them about fees before the surgery. I have Medicare as a secondary (I'm disabled) and they will pay a small portion of the bill as long as I follow the primary insurances' policy of using an in-network physician. So, I am trying to convince Aetna to cover Dr. Wolford as in-network since they don't offer an OS in network within 100 miles of my home. I am also having the correction surgery for sleep apnea at the same time. I will keep plugging away and with all the great input from this website and more appeals I hope to conquer this beast yet.

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