AboutTricia Expertise Has your medical insurance company denied your claim and refuses to pay? Have
you received a pre-authorization and still your insurance company
refuses to pay? How can you get your insurance company to reverse a
denied claim? How do you get a provider to waive your copayment if you
are financially unable to pay? Can a provider sue you for a unpaid bill and
will they? Can a provider send me to a collection agency for a medical bill?
If my insurance company does not pay, am I responsible? If you have these questions or others on why your insurance company is not paying your bills, I can help. I can give you "tricks of the trade" to get your insurance company to pay.
I have limited knowledge on Medicare and Medicaid and that is not my expertise. Each state is very different regarding Medicare and Medicaid so you need to review their website when you have questions. So please no Medicare or Medicaid questions!!
Experience In the medical field for over 20 years spending majority of time in the collections aspect.
Question QUESTION: I have been denied part of my surgery by Aetna Insurance. Dr. Larry in Dallas, Texas has diagnosed me with Bilateral TMJ arthritis and disc dislocation, Maxillary hypoplasia, Mandibular hypoplasia, pain, non union of jawbone, and decreased airway. Aetna approved the TMJ joint surgery which I had on 5/6/08 but still has denied me the remainder of my surgery which is Multiple maxillary osteotomies with bone plate stabilization and grafting, bilateral mandibular ramus osteotomies with bone screw stabilization.
I presently have a 5mm ROM and no lateral movement and a 4mm restricted airway which 11mm is considered normal. I have lost all jaw function and also suffer from non-union of jawbone that Dr. was going to correct with grafting. My upper palate is so narrow that it affects my speech because my tongue does not fit in my upper palate. My doctors feel my misaligned jaw is causing my joint problems and function problems and if not corrected my condition will not get any better. I am unable to eat because of my 5mm ROM.
At this time Aetna has just denied my second appeal using cosmetic reasons as the reason for denial and feels braces can correct my problem. I am in my third set of braces and each time have had a major relapse when the braces are removed. I had a Lefort surgery and Arthroscopic surgery which both have failed.
Dr. W is well known for taking on complicated cases as mine and has high hopes that he can correct my medical problems and improve my quality of life. He stated to Aetna that my 4mm airway is life threatening. I have also provided Aetna letters from five other doctors stating my surgeries are medically necessary. I contacted over 20 doctors in the DC area last year and all informed me that my case was too complex for them to handle and referred me to Dr. Larry W. Last week my local doctors updated Aetna that my 5mm ROM and no lateral movement has not shown any improvement. Despite all of this Aetna continues to deny my surgeries. I spoke to Virginia Insurance Commission and he informed me that under Virginia State Laws my surgery is required to be covered, but my insurance plan is self insured so he stated he could not help out.
This has put a financial strain and hardship on my family because I have endured over eight complication surgeries and now denied part of a surgery that is medically necessary to put these complication surgeries to an end. I have spent hundreds of hours on the phone with Aetna trying to get approval and now since they didn't approve my entire surgery when I get approval I will have to pay again a plane ticket back to Dallas, Texas, hotel accommodations for up to two weeks. I also will have to endure five more months of suffering in pain that could have been avoided if Aetna would have approved all procedures. I have been on continuous painkillers since December of last year and will have to continue on this medication since my jaws are not lined up properly causing major muscle spasms. At this point I feel Aetna should be prosecuted to the fullest for not approving me surgery despite the 50 or more pages of documentation that was sent in warranting why this surgery is medically necessary.
ANSWER: Hi Karen!
Unsure what your question is......however sometimes if you go public such as TV or the newspaper, carriers seem to listen.
Good Luck!
Tricia
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QUESTION: Aetna keeps informing me they are following guidelines which is why they keep denying my appeals despite my doctor's stating my case is very complex and warrants jaw surgery. I keep trying to bring up to Aetna that no where in their clinical guidelines do I see anything about correcting non-union of jawbone, high upper arch that is more than half of what is normal, narrow upper palate, etc., I have written letters to senators, congressman, Dept. of Labor, etc. My insurance plan is self insured and is exempt from following state laws which requires my surgery to be covered. How do we convince the insurance company that even though my case doesn't follow Aetna's clinical guidelines my complex case still warrants medical necessity. My upper palate is so narrow that my tongue does not fit in the upper palate which affects my speech. My doctors have written Aetna stating they feel that my misaligned jaws are causing my ROM issues and joint issues. What do you suggest in convincing my HR department that this surgery is medically necessary even though it doesn't strictly follow Aetna's guidelines? I tried to explain to my HR department that all patients should not be expected to follow under the same guidlines because their cases may be different. In my case I suffer from underdeveloped upper and lower jaw, non-union of jawbone, misaligned jaws, continuous relapses, limited ROM at 5mm, no lateral movement even after joint procedures, etc.
Answer With most insurance you can only usually appeal twice then after that they won't even look at your appeal......so you need to get someone with some pull involved. Again I would suggest the media or perhaps the governor........
I am sure if you keep trying you may get someone to help you.
There are many a procedure that is medically necessary that insurance companies refuse to pay. Most of the time it is due to the high cost.
