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a saga.
An epic? At any rate, a tale.
So I used to live in the near suburbs on the other side of town, right. And then I got this job, and with it came various insurances, including dental, and I picked a dentist near where I lived, and all was groovy.
And then I moved - but when I asked my dentist, whom I liked a lot, if he could recommend a colleague near where I was moving to, and he all he had was someone he knew thirty miles away (because he has no concept of where things are on this side of the state line), I thought, you know, I go to the dentist twice a year, I can live with coming back down to this office.
Then my employer changed dental plans - well, they changed from offering two choices to offering one. Guess which one I'd had? So I had to switch to the other one, which fortunately my dentist's office also took, so I changed over, no problem. Except there was a problem, because they weren't taking new patients with that insurance - so the dentist's office knew I wasn't a new patient, but it took three phone calls with the insurance company to persuade them that I was an existing patient, grandfathered in under their old participation arrangement or whatever they call it, and this should be my primary dental office in their computer records there. (They had preemptively assigned me a primary dental office I'd never heard of, which I assume was based on proximity alone - not irrelevant, but not what I wanted, especially when I was at the dentist's for an appointment I'd already made.) Whew.
Several months go by. Then this spring, as you may remember, I had a headache that didn't go away for three weeks. The allergist sent me for a CAT scan and gave me antibiotics, and when those didn't work he sent me (with my pictures) to an ENT, and the ENT poked until I said "ow" and sent me to a dentist downstairs who could deal with my TMJ.
The new dentist takes my insurance!, so all is well. Only some of what he recommends isn't covered; I live with that and shell out $1900 for an occlusal orthotic because if it realigns my jaw and makes my head stop hurting it'll be worth it. But still: some of it should be covered. Only it gets bounced by the insurance company because the claim was submitted without a referral. [eyeroll] So I ask the ENT to send a referral to the dentist's office, and they resubmit the claim, and on we go.
And one time while I'm there it turns out that some other pain I've been feeling is due to cracks in two of my teeth. So he drills those out and puts in the temporary and it was yesterday that I went back in to get the porcelain onlays, and I brought along an Explanation of Benefits where the insurance had bounced the x-ray claim for having been submitted without a referral, intending to ask the office manager if I seriously needed a different referral for follow-up care - and before I could get to it, she said that in the latest conversation she'd had with the insurance people, they'd told her they couldn't pay any of my claims, because I'm on a dental HMO and they're not my primary office.
[boggle] The outstanding balance was another four figures, mind you, and apparently because the new dental office is a participant but only in the PPO and not in the HMO I'm screwed? That was the bottom line, and I didn't quite follow the conversation as the lovely office manager explained it to me, in which she'd gone to bat to try to get the insurance to cover my claims - blah blah blah, she said, and "well, that doesn't matter," they'd said, and "well, it matters to my patient!", she'd said, and I don't even know. But I can always appeal. Right. Also, I believe the PPO is available to me, and here we are in Open Enrollment season. So I paid the next 3K and got beaten to a pulp, as you saw yesterday, and today I braced myself for some phone calls.
Turns out Open Enrollment closed Wednesday night, so that option won't be available to me until next year. So the insurance person I spoke to today said the PPO vs. HMO thing didn't make any sense to her, except that because I'm on the HMO I can't see another dentist without a referral from the primary one. They are not interested in the referral from the ENT, because his degree is MD and they don't care if your degree isn't DDS. Go figure. This insurance person is reeeasonably sure that if I resubmit the claims with a written referral from the primary dental office, they may be approved. At the very least, they'll be rejected for a whole different reason. :-/
The primary dental office is happy to provide a written referral going forward, but obviously can't back-date one, so we'll see how that goes. And they've asked for a copy of the ENT's referral, so they can review and honestly say whether they concur, which their office manager said she's sure they will. So I call the new dental office, which is closed on Fridays, intending to leave a message for the office manager there - and I get the dentist himself, who's in there on his own doing four different things and ack. Fortunately he suggests what I would have suggested if he'd let me, which is hanging up and calling back and letting it roll to voice mail.
So we'll see. I am only very slightly optimistic that with a referral dated 3/24 from the ENT and a referral dated 5/24 from the original dentist, the insurance will pay all the claims with dates in the intervening two months. But a small chance is better than no chance at all.
So I used to live in the near suburbs on the other side of town, right. And then I got this job, and with it came various insurances, including dental, and I picked a dentist near where I lived, and all was groovy.
And then I moved - but when I asked my dentist, whom I liked a lot, if he could recommend a colleague near where I was moving to, and he all he had was someone he knew thirty miles away (because he has no concept of where things are on this side of the state line), I thought, you know, I go to the dentist twice a year, I can live with coming back down to this office.
Then my employer changed dental plans - well, they changed from offering two choices to offering one. Guess which one I'd had? So I had to switch to the other one, which fortunately my dentist's office also took, so I changed over, no problem. Except there was a problem, because they weren't taking new patients with that insurance - so the dentist's office knew I wasn't a new patient, but it took three phone calls with the insurance company to persuade them that I was an existing patient, grandfathered in under their old participation arrangement or whatever they call it, and this should be my primary dental office in their computer records there. (They had preemptively assigned me a primary dental office I'd never heard of, which I assume was based on proximity alone - not irrelevant, but not what I wanted, especially when I was at the dentist's for an appointment I'd already made.) Whew.
Several months go by. Then this spring, as you may remember, I had a headache that didn't go away for three weeks. The allergist sent me for a CAT scan and gave me antibiotics, and when those didn't work he sent me (with my pictures) to an ENT, and the ENT poked until I said "ow" and sent me to a dentist downstairs who could deal with my TMJ.
The new dentist takes my insurance!, so all is well. Only some of what he recommends isn't covered; I live with that and shell out $1900 for an occlusal orthotic because if it realigns my jaw and makes my head stop hurting it'll be worth it. But still: some of it should be covered. Only it gets bounced by the insurance company because the claim was submitted without a referral. [eyeroll] So I ask the ENT to send a referral to the dentist's office, and they resubmit the claim, and on we go.
And one time while I'm there it turns out that some other pain I've been feeling is due to cracks in two of my teeth. So he drills those out and puts in the temporary and it was yesterday that I went back in to get the porcelain onlays, and I brought along an Explanation of Benefits where the insurance had bounced the x-ray claim for having been submitted without a referral, intending to ask the office manager if I seriously needed a different referral for follow-up care - and before I could get to it, she said that in the latest conversation she'd had with the insurance people, they'd told her they couldn't pay any of my claims, because I'm on a dental HMO and they're not my primary office.
[boggle] The outstanding balance was another four figures, mind you, and apparently because the new dental office is a participant but only in the PPO and not in the HMO I'm screwed? That was the bottom line, and I didn't quite follow the conversation as the lovely office manager explained it to me, in which she'd gone to bat to try to get the insurance to cover my claims - blah blah blah, she said, and "well, that doesn't matter," they'd said, and "well, it matters to my patient!", she'd said, and I don't even know. But I can always appeal. Right. Also, I believe the PPO is available to me, and here we are in Open Enrollment season. So I paid the next 3K and got beaten to a pulp, as you saw yesterday, and today I braced myself for some phone calls.
Turns out Open Enrollment closed Wednesday night, so that option won't be available to me until next year. So the insurance person I spoke to today said the PPO vs. HMO thing didn't make any sense to her, except that because I'm on the HMO I can't see another dentist without a referral from the primary one. They are not interested in the referral from the ENT, because his degree is MD and they don't care if your degree isn't DDS. Go figure. This insurance person is reeeasonably sure that if I resubmit the claims with a written referral from the primary dental office, they may be approved. At the very least, they'll be rejected for a whole different reason. :-/
The primary dental office is happy to provide a written referral going forward, but obviously can't back-date one, so we'll see how that goes. And they've asked for a copy of the ENT's referral, so they can review and honestly say whether they concur, which their office manager said she's sure they will. So I call the new dental office, which is closed on Fridays, intending to leave a message for the office manager there - and I get the dentist himself, who's in there on his own doing four different things and ack. Fortunately he suggests what I would have suggested if he'd let me, which is hanging up and calling back and letting it roll to voice mail.
So we'll see. I am only very slightly optimistic that with a referral dated 3/24 from the ENT and a referral dated 5/24 from the original dentist, the insurance will pay all the claims with dates in the intervening two months. But a small chance is better than no chance at all.