Why I became a patient advocate

I was a meteorologist with the National Weather Service when I was going through my jaw journey. I was doing a lot of patient outreach through my website and other various forums. The opportunity presented itself to make this a full time gig and I jumped on it. Through my turbulent surgery experience I learned how to not only navigate things in terms of getting me taken care of medically, but I also learned how to navigate the difficult insurance system here in the U.S. I get a lot of joy helping others work through their paths to get the care they need.

So, what does that mean? I get to learn more information about all of this to be able to share with you. And I can offer my services professionally. Do you have out-of-network claims sitting that never get filed? Have you been done over by your insurance on something and you want to fight them? Appeal a bill? Negotiate a bill? Not sure if the coding used for your bill was correct and the best for maximum reimbursement? Not sure if your insurance has reimbursed you right on something?Need help getting the care you need or need someone to advocate for you in any way with your doctor or insurance? Check out the company I work for. We're working to make the confusing process of getting care and working with your insurance as easy as we can for you. Download our app, give us permission to speak on your behalf with your providers and insurance to make sure you are getting the maximum you can for your care and associated insurance reimbursements. If something is wrong with the way things are coded, we'll work to get that fixed. If your insurance company is trying to pull one over on you and not reimburse you to the fullest extent, we'll go to bat for you and make sure you get the money your insurance owes you. Once you download our app, all you have to do is take a picture of your superbill when you leave your doctors office and send it to us through the app. Sit back and relax while we take care of the rest. Check us out at Better! Click on the image below to go to our website and sign up. 

​Insurance FAQ and help

There are so many hurdles to get over in the whole jaw surgery process and if you are in the U.S, then a battle with insurance will probably be one of them. Many of the inquiries I get from my website are about insurance. I also see many of the same questions on various groups and message boards, so I wanted to make a section of my website to cover some of this topic.

Number one question I see: Will my insurance cover my jaw surgery? Not always. Jaw surgery is strictly considered through your medical coverage. Of course not all medical plans are created equal. Most plans have minimum criteria to consider jaw surgery a medically necessary procedure that they will cover, IE: skeletal discrepancy of at least 5mm, sleep study showing apnea, nutritional deficiency because your bite is so off, etc. Here is a checklist when first examining if you will have coverage or not:

• Is orthognathic surgery a covered benefit in your insurance? Check your plan. It may be excluded all together no matter how severe or medically necessary your issues are. If your plan totally excludes this you do have the option of appealing with your insurance and looping in the help of your states department of managed care, but it is my experience that appeals of this sort are generally not granted unless it's a situation like your insurance previously covered this surgery and changed to not covering it in a new plan year. You can appeal on the basis that you were a member for X years, thought this was still a covered benefit, and would like for them to honor their previous coverage for this type of care. Even that is a long shot, but it's worth trying. Worst thing that happens is they tell you no.
• If orthognathic surgery is a covered benefit, then you're good to go, right? Not always. Here is where the medically necessary parts come in, and this is an incredibly frustrating area to be in as a patient because of course your jaw issues feel like a crisis to you and warrant insurance coverage to fix, but sadly you do have to meet certain minimums with certain plans. Some plans have little to no minimums, but I am confident saying it's unfortunately not the case with most plans. ​Take for example my plan-- my primary coverage was Blue Cross Blue Shield Federal Employee Program. I actually can't even tell you what their minimums are with certainty. I want to say it was 5 or 6mm on the discrepancy plus whatever supporting narrative you had to show it was medically necessary. My surgeons office wasn't at all worried about me getting approved. They work with this plan a lot and know what gets covered and what doesn't. My secondary was Anthem Blue Cross. My pre-authorization for surgery was put in a few weeks ahead of my surgery and I think there was some drama about BCBS not receiving the entire package my surgeon sent over with my records and a narrative from him describing the issues and why the surgery was needed, but once they had all of that I had zero issues getting approved and covered. You also have the option of doing research yourself (or through the company I work for linked above) and finding out your benefits ahead of time. Get your diagnosis code and CPT (procedure) codes from your surgeon for what you'll have done. Get your measurements. Call your insurance and find out if based on the diagnosis and CPT codes alone this is a benefit of your plan. 
• What happens if jaw surgery is a benefit of my plan but my preauthorization gets denied? This is a situation where your surgeon's office is your best friend. They can make or break these things by sending in the right records with the right narrative for you. They can also request a review where a specialist from your insurance company will call and talk to them. They make the case why your jaw surgery is medically necessary. Sometimes surgeons don't do a great job here, so we have to advocate for ourselves. Call your insurance and ask what they need. Talk to your surgeons office and make sure all of that has been sent in to your insurance. If everything is in to the fullest and you still get a denial, then you may be in a space where what you have going on truly does not meet the minimum requirements to be considered medically necessary by your insurance. Your next step is to write up an appeal to submit to your insurance. This is another service my company can take care of, so if you're in this position feel free to check us out and we will try to get you a better outcome on your insurance denial.
• Insurance is covering my surgery, but it's not that much: Check your plan's benefits. It should be clear in your plan how much your insurance will pay. The wildcard in this is allowed amounts. Every insurance is different with those, and even within the same insurance, they fluctuate like gas prices. It also depends on what part of the country you are getting care in. A surgeon in San Francisco or New York will have a higher locality allowable amount vs. a surgeon in BFE nowhere South Dakota. Feel free to call your surgeon and get your diagnosis and procedure (CPT) codes that will be billed and call your insurance to ask what the allowable amounts will be. Your insurance might tell you they don't do this, but do not let them bulldoze you. It's your right to know these numbers and it is illegal for them to not provide them to you. It can be considered them restricting your access to care because you are making medical decisions based on these numbers. If they try to bully you here, ask for a supervisor and escalate it until they answer your question. Be firm. Let them know what they are doing is illegal and preventing you access to care you need. The other big issue here is if you are going out-of-network or in-network. In-network is obviously the better option. Your plan's allowable amounts may be higher and they will ultimately reimburse more. Your surgeon is on the hook for anything over the contracted allowable rate, where if you go out-of-network, YOU are on the hook for that. It will first be subject to your out-of-network deductible and then your plan will pay a percentage after that. Usually somewhere between 50-70% of the allowable amount. This is where patients get in to a lot of trouble. Your surgeon can bill a $10,000 surgery, but your plan has a "reasonable and customary" allowable amount of $5,000. If your surgeon was in-network, then you are not responsible for anything over that $5,000. If your surgeon is out-of-network, then you are on the hook for that $5,000 over their allowed amount of $5,000, and if your plan reimburses 50% for your out-of-network care, then you are only getting $2,500 back from your plan on a $10,000 bill.  

What I did for my case: I was with Kaiser HMO after my first surgery. I was stuck with them for the entire year, so after my April surgery I was left paying out of pocket for all of the surgeon and various consults I went on the rest of that year. When I found the revision surgeon I wanted in Aug 2014, I had a chat with their office and asked them what insurance works best for their office. I had open season coming up in November and wanted to make a clean switch to something that would maximize my benefits with this particular office. They said they are in-network with delta dental and Blue Cross Blue Shield. The only hiccup was the hospital that my surgeon operates out of was out-of-network with Blue Cross Blue Shield, but they let me know if I could pick up a secondary insurance somehow that they prefer Anthem Blue Cross and operate in-network with them. I was very fortunate in my case. When open season came up for both my husband and I in November of 2014, I was able to pick up Federal Employee Blue Cross Blue Shield through my employer, and he was able to get Delta Dental and Anthem Blue Cross through his. I got double coverage that ended up more than covering me for all of my care the next 2 years through revision. I think my surgeon billed something like $18,000 for my surgery. Contracted rate (allowed amounts) were something around $9,000. I was responsible for a $1,700 co-pay out of that and insurance paid the rest. Unfortunately my Anthem secondary did not pitch in towards that $1,700 that I was out-of-pocket because my surgeon was out-of-network for them and their allowed amounts were actually less than what my primary paid, so it means they were off the hook. I think the hospital charged something around $22,000. My primary didn't pick up much because it was out-of-network for them. My Anthem secondary paid the rest. I had something like a $35 bill I paid for anesthesia and that was it. I can't recommend this approach enough. It worked out incredibly awesome for me and it was quite smooth. I had no issues with my pre-authorizations and any payments. The only hiccup was I was a little irritated that my secondary did not pitch in for the $1,700 I was out-of-pocket with my surgeon, but after talking with Anthem and appealing, I learned it is what it is there and in the grand scheme of things I got off really well for what I was out to pay for my revision care. 

Jaw surgery is such an overwhelming and intensive process to begin with, and worrying about insurance makes it that much more difficult. Hopefully some information I provided can help. If you are interested in having professional help with all of this, please visit my companies website and sign up for our app. We can be an incredible resource for all of this, especially if you are trying to navigate out-of-network care.