Help with dental and medical surgery

[waverly]

DS (13) has a small mass above his last adult molar which is causing it to be impacted. His wisdom tooth in that area is also causing problems. 

We went to an oral surgeon who would charge us 11K because the molar work and taking out wisdom teeth is covered under dental, but the small mass (which honestly is probabaly tooth material) is not covered.  Apparently, this is under our health insurance and they are out of network with our health insurance. So basically the amount they would bill is equal to our out of network deductible which is in the 5K range.  11k is OOP after dental insurance. 

So I went to the insurance company to see who was in both dental and medical and I got a few names.  But, one number I called was with the wrong doctor and they are also out of network with all health insurances. The other number that I called is disconnected.  Thank you insurance company. 

I have one more office to call, but I feel like I am out of options and not really sure what to do.  One office suggested I ask the pediatrician for a medical provider.  I called and left a message and the pediatrician never called me back. 

Apparently some doctors do oral surgery as medical and some as dental and it depends on what practice it is billed out of maybe? Or does it depend if it is a hospital versus the office? 

Is anyone familiar with this space and can help me?  I understand that dentists bill both and medical pays for some of it maybe anesthesia or something, but the people I talked to had medical cover it with no issue.  And I can't figure out why I can't get in network medical to cover the medical part of his surgery.  I was told that most dentists are out of network with medical but aren't some oral surgeons medical?  I had this same problem with TMJ issues and decided to forgo additional treatment due to that.   

[waverly]

Should I try the children's hospital?

[sent]

I am familiar with this stuff, you can message me.

Many private practice oral surgeons have decided they don't want to mess with billing medical because it is an enormous time suck. So they remain out of network and as you've found, the patient can then take it or leave it.

This is also very location dependent so there could be oral surgeons that will bill medical and dental and not necessarily cost you $11K out of pocket.

[waverly]

Apr 23, 2024 12:28:05 GMT -5 sent said:

I am familiar with this stuff, you can message me.

Many private practice oral surgeons have decided they don't want to mess with billing medical because it is an enormous time suck. So they remain out of network and as you've found, the patient can then take it or leave it.

This is also very location dependent so there could be oral surgeons that will bill medical and dental and not necessarily cost you $11K out of pocket.

They will bill medical but they are out of network so the amount they bill around 5-6K is about the same as our out of network deductible.  I will PM you if you have ideas on Oral Surgeons that will bill in network medical in my area.  

[mommyatty]

waverly, if they gave you names, and none panned out, can you ask them to cover your original doc as in network? Our medical insurance has that option if there are no in network providers in your general area. Not sure if that’s a universal thing or not.

[mccallister84]

Have you looked for an oral maxillofacial surgeon? I had to have a massive jaw surgery and that was who performed it. Mine was covered fully under medical, but the doctor who performed it was actually a dds/md so perhaps he would have billed dental as well had it been needed.

[sent]

Apr 24, 2024 6:13:16 GMT -5 mccallister84 said:

Have you looked for an oral maxillofacial surgeon? I had to have a massive jaw surgery and that was who performed it. Mine was covered fully under medical, but the doctor who performed it was actually a dds/md so perhaps he would have billed dental as well had it been needed.

oral maxillofacial surgeon = oral surgeon

It is the same specialty. They can perform the same procedures. Some of them have the MD, some don't depending on where they trained and how long their residency was. The residency with the MD is a 6 year program, the one without the MD is a 4 year program. This is all 4 years after graduation dental school with a DDS or DMD.

(DDS = DMD, they are the same exact degree, the "DMD" came about from the schools that translated their degrees from Latin)

[sadlebred]

Also ask if they have a "cash price." It might get you a discount.

[christy082]

Apr 23, 2024 22:21:36 GMT -5 mommyatty said:

waverly, if they gave you names, and none panned out, can you ask them to cover your original doc as in network? Our medical insurance has that option if there are no in network providers in your general area. Not sure if that’s a universal thing or not.

I used to work for an insurance company and they called this a "network deficiency request ". I would also recommend requesting this.

[mccallister84]

Apr 24, 2024 9:39:51 GMT -5 sent said:

Apr 24, 2024 6:13:16 GMT -5 mccallister84 said:

Have you looked for an oral maxillofacial surgeon? I had to have a massive jaw surgery and that was who performed it. Mine was covered fully under medical, but the doctor who performed it was actually a dds/md so perhaps he would have billed dental as well had it been needed.

oral maxillofacial surgeon = oral surgeon

It is the same specialty. They can perform the same procedures. Some of them have the MD, some don't depending on where they trained and how long their residency was. The residency with the MD is a 6 year program, the one without the MD is a 4 year program. This is all 4 years after graduation dental school with a DDS or DMD.

(DDS = DMD, they are the same exact degree, the "DMD" came about from the schools that translated their degrees from Latin)

Here was my experience, and to be fair I do not know what route OP has taken so she may already be at a doctor number 2.

I needed wisdom teeth pulled the year before I needed the extensive surgery (this was all part of a years long treatment plan). Doctor 2 would not do just wisdom teeth extraction. So I had that done with Oral Surgeon Doctor 1 - he was the oral surgeon who worked with my dentist and basically was at a different dentist’s office once a week extracting wisdom teeth. He was a DDS. And he was wonderful. No complaints. He was not willing to do the much larger surgery. Now, I have no idea if he was able to or not. It could have very much just been outside of the scope of his practice. But his practice/work was very clearly teeth focused if that made sense.

Doctor 2 was the DDS/MD. He solely works on medical issues related to the jaw and face. This is from his practice’s website - all the doctors in that office are DDS/MDs. To me, they seem more medical focused than teeth focused for lack of better terms.

Oral Cancer/Pathology
Salivary Gland Cancer/Pathology
Head and Neck Cancer
Thyroid Cancer
Hard and Soft Tissue Facial Reconstruction
Robotic Surgery
Osteoradionecrosis
Jaw Tumors & Cysts
Cleft-Lip and Palate Surgery
Pediatric oral/head-neck pathology
TMJ Surgery
Adult and Pediatric Sleep Apnea Surgery
Corrective Jaw Surgery
Distraction Osteogenesis
Craniomaxillofacial Trauma
Dental and Zygomatic Implants
Dentoalveolar Surgery

He was qualified to extract my wisdom teeth. But he wouldn’t do that as a stand alone procedure. Because he’d rather spend his days doing the above.

So I am wondering if the OP found a doctor like my Doctor #2 that she might have more luck getting things covered.

[waverly]

I'm still no where mccallister84 . I ran a new list through the insurance because I called the last people on my old list and they were having contract conflicts so no longer with that insurance in network.

Ironically Doctor 1 shows up in network at a certain office. I call that number disconnected. I figure out that some of the oral surgeons that work for that practice (4 locations) are in network but not all of them. Why aren't they all in network?

I email the office to see if they can bill my health insurance in network. Yes, I should call but I am at work wasting my time on this in a shared office with my boss, so email is better.

I found another practice with 2 doctors that appear to maybe be in network. So the problem is that they show in network on health insurance side but when I call to find out, they are not. I also emailed them to see if they are in network.

[waverly]

Apr 24, 2024 10:04:22 GMT -5 christy082 said:

Apr 23, 2024 22:21:36 GMT -5 mommyatty said:

waverly , if they gave you names, and none panned out, can you ask them to cover your original doc as in network? Our medical insurance has that option if there are no in network providers in your general area. Not sure if that’s a universal thing or not.

I used to work for an insurance company and they called this a "network deficiency request ". I would also recommend requesting this.

This is interesting.  I wonder how that works though if insurance has a list of those in network, but when I talk to the actual office they tell me they are out of network.  

How do I prove there is a network deficiency request?  Maybe letters from all the dentists or offices saying they are out of network? 

[christy082]

Apr 24, 2024 10:29:03 GMT -5 waverly said:

Apr 24, 2024 10:04:22 GMT -5 christy082 said:

I used to work for an insurance company and they called this a "network deficiency request ". I would also recommend requesting this.

This is interesting.  I wonder how that works though if insurance has a list of those in network, but when I talk to the actual office they tell me they are out of network.  

How do I prove there is a network deficiency request?  Maybe letters from all the dentists or offices saying they are out of network? 

In my experience, when a request was received, a member of the administrative support staff at the insurance company did research/calls to providers to see if the deficiency was supported.

[sent]

Apr 24, 2024 10:29:03 GMT -5 waverly said:

Apr 24, 2024 10:04:22 GMT -5 christy082 said:

I used to work for an insurance company and they called this a "network deficiency request ". I would also recommend requesting this.

This is interesting.  I wonder how that works though if insurance has a list of those in network, but when I talk to the actual office they tell me they are out of network.  

How do I prove there is a network deficiency request?  Maybe letters from all the dentists or offices saying they are out of network? 

The insurance websites are not always accurate regarding if the office is in or out of network. They may have been in at one point, and then went out but the insurance hasn't updated on their end.

[sdlaura]

I'm not sure how soon this would kick in, but if it's not a super immediate need for surgery, we have dual dental insurance through both of our jobs, so that really helps with things like this in terms of getting more coverage, even for out-of-network dentists. If both of your jobs offer dental insurance, it might be worth looking into adding it for whichever one you don't use currently.

[waverly]

sdlaura, that is a thought for the dental portion of it anyway. The main issue is the medical procedure that isn't covered by dental, but the dental also has pretty low (although typical) limits.

sent, I know that the insurance websites aren't always accurate because well lets be honest it is a hot mess. In fact they only let me search once and then the other times I try the search results don't display correctly. I've also reached out to the insurance company itself for lists, but they use the same source.

[sent]

Apr 24, 2024 12:13:58 GMT -5 waverly said:

sent , I know that the insurance websites aren't always accurate because well lets be honest it is a hot mess. In fact they only let me search once and then the other times I try the search results don't display correctly. I've also reached out to the insurance company itself for lists, but they use the same source.

I would push for what christy082 suggested if there truly are no oral surgeons in network with your plan. I would believe the office telling you they are out of network over the insurance company claiming they are in network. 

[waverly]

sent, yes, so I sent a message to my insurance asking for that.

They sent me a list of providers. Same list as before where numbers were wrong, they weren't actually in network, contract dispute etc. I let insurance know that and they said they cannot fix the phone numbers becuase the doctor provides them.

I may have found someone in the medical and dental networks. The confirmed over the phone that they are, and we set up an appointment. If that falls through, I am going to keep going with the network deficiency request. We are scheduled about a month out which is fine becuase I was hoping to do it when DS was out of school for the summer.

[sent]

mccallister84 , Doctor 2 was definitely a residency-trained oral and maxillofacial surgeon who likely went to a 6 year residency program after dental school that awarded an oral surgery certificate and an MD. We usually call them all "oral surgeons" for short but really when we use the term "oral surgeon" we mean "oral and maxillofacial surgeon."

Doctor 1 could have also been a residency-trained oral and maxillofacial surgeon. He may have gone to a 4 residency program after dental school where they only award an oral surgery certificate and there is no time or opportunity to earn the MD. He would have been trained in all the procedures listed on doctor 2's website during his residency. However, he may also have decided at some point in his career to limit his scope of practice and only focus on wisdom teeth and other extraction type procedures.

There are also residency-trained oral and maxillofacial surgeons like doctor 2 who go to programs where they earn an MD, but when they finish residency they set up a practice where they mostly do procedures like Doctor 1. So even though the credentials after the name says "DDS, MD," and they were trained to do the medical-type procedures you listed form doctor 2's website, they won't expand their scope in private practice to do them.

If this is confusing, it's because it is mostly about $$$$ but it is also about risk. Most of the procedures on doctor 2's website carry more risk of malpractice so many trained oral surgeons won't do them although there is a real need for them. I bet if the reimbursements for those procedures were higher (like the $11K quote OP was given,) lots more doctors would take the risk and do them.

The third scenario possible in your situation is that Doctor 1 may have been a general dentist who likes taking out wisdom teeth and visits your dentist's office periodically to do mainly that procedure. This person did not do an oral and maxillofacial residency after graduating from dental school. They have a DDS but no MD like doctor 1 but are not residency-trained like doctor 1. This person is a general dentist who likes doing oral surgery procedures and that is allowed. Practicing like this is within the scope of a dental license, but they are not supposed to call themselves an oral surgeon even if all they do is oral surgery. But patients get confused and call this person an oral surgeon anyway.

[mccallister84]

Apr 24, 2024 16:29:38 GMT -5 sent said:

mccallister84 , Doctor 2 was definitely a residency-trained oral and maxillofacial surgeon who likely went to a 6 year residency program after dental school that awarded an oral surgery certificate and an MD. We usually call them all "oral surgeons" for short but really when we use the term "oral surgeon" we mean "oral and maxillofacial surgeon."

Doctor 1 could have also been a residency-trained oral and maxillofacial surgeon. He may have gone to a 4 residency program after dental school where they only award an oral surgery certificate and there is no time or opportunity to earn the MD. He would have been trained in all the procedures listed on doctor 2's website during his residency. However, he may also have decided at some point in his career to limit his scope of practice and only focus on wisdom teeth and other extraction type procedures.

There are also residency-trained oral and maxillofacial surgeons like doctor 2 who go to programs where they earn an MD, but when they finish residency they set up a practice where they mostly do procedures like Doctor 1. So even though the credentials after the name says "DDS, MD," and they were trained to do the medical-type procedures you listed form doctor 2's website, they won't expand their scope in private practice to do them.

If this is confusing, it's because it is mostly about $$$$ but it is also about risk. Most of the procedures on doctor 2's website carry more risk of malpractice so many trained oral surgeons won't do them although there is a real need for them. I bet if the reimbursements for those procedures were higher (like the $11K quote OP was given,) lots more doctors would take the risk and do them.

The third scenario possible in your situation is that Doctor 1 may have been a general dentist who likes taking out wisdom teeth and visits your dentist's office periodically to do mainly that procedure. This person did not do an oral and maxillofacial residency after graduating from dental school. They have a DDS but no MD like doctor 1 but are not residency-trained like doctor 1. This person is a general dentist who likes doing oral surgery procedures and that is allowed. Practicing like this is within the scope of a dental license, but they are not supposed to call themselves an oral surgeon even if all they do is oral surgery. But patients get confused and call this person an oral surgeon anyway.

Thank you for clarifying. It has been over a decade, but I’m thinking that my first “oral surgeon” was probably the last example you talked about. And like I said earlier, he was wonderful. To be fair I can’t even tell you that he called himself an oral surgeon.

[wanderingback]

Apr 24, 2024 10:28:06 GMT -5 waverly said:

I'm still no where mccallister84 . I ran a new list through the insurance because I called the last people on my old list and they were having contract conflicts so no longer with that insurance in network.

Ironically Doctor 1 shows up in network at a certain office. I call that number disconnected. I figure out that some of the oral surgeons that work for that practice (4 locations) are in network but not all of them. Why aren't they all in network?

I email the office to see if they can bill my health insurance in network. Yes, I should call but I am at work wasting my time on this in a shared office with my boss, so email is better.

I found another practice with 2 doctors that appear to maybe be in network. So the problem is that they show in network on health insurance side but when I call to find out, they are not. I also emailed them to see if they are in network.

Each individual provider decides and has to submit an application to each insurance company to be credentialed with them. It is a huge hassle. So for a variety of reasons 1 doctor in the same location as another might not accept the same insurance.

I know this personally cause I’m in the medical field but it happened to me recently with a dermatology appointment. My work switched insurance that my very occasional dermatologist doesn’t take. So I had to cancel an appointment but was able to reschedule with another doctor there that took my insurance.

Where I work for whatever reason it took awhile for a few of the providers to be credentialed with a new insurance admin decided we should accept. So for awhile I was the only physician who could see patients with X insurance. So anyway, just some info about why different doctors have different insurance options they accept.

[sent]

I have had the same issue as wanderingback , getting all of us credentialed in my office. It took one company 11 months to put two of us in network. We sent our completed applications. Four months into the process, they had some turnover and said we had to start the process all over. Then it took them 7 more months to put us in the network so we could get paid because this is a Medicaid HMO so these patients have no out of network benefits if they come to us. I have to add another doctor to this network and I'm nervous about the timeline. This particular doctor that I have to add used to be in network with this plan four years ago when she worked somewhere else. She had a baby, left that practice, had another baby, joined my practice, and then had a third baby last summer. But we have to reapply for her as a fresh new doctor being added to their network because they need to do their research and make sure she hasn't been up to criminal and illicit things over the past 4 years in between working part time and taking care of 3 kids. Even though 4 years ago they were totally ok with her seeing their patients at a different office.

[waverly]

That makes sense wanderingback and sent .

The problem is when I call the office that the doctor works at then they say they are out of network. So I think the office doesn't bill the health insurance, but some offices do. So then I need to figure out what office bills for that doctor or if no offices bill for that doctor to the health insurance. They move around to different offices throughout their careers, so some might be old information or they are in 3 different offices every week.  They may have gotten credentialed with the insurance, but the office doesn't want to deal with it/ submit it? 

When I reached out to the insurance to let them know that they had bad phone numbers for at least 3 doctors on their list of lets say 8 doctors and that 3 listed are in contract disputes, they let me know that they cannot update or correct their information because it is submitted by the doctors, so the doctors submitted it wrong. OK so continue to send out the wrong phone numbers to all your insureds then.

[sent]

I am going to preface this with I've become so cynical lately.

waverly I'm sorry this is becoming a difficult situation to navigate.

This process is probably by design on the insurance company's part. The more inefficient their network is, the less likely you will be able to use the insurance you paid for. Some motivated policy holders like yourself will probably keep on top of this but they gamble that most won't. Keep pushing for that gap exception. Escalate it beyond the person assigned to say "oh the doctors sent us the wrong phone numbers."

I know I regularly see names of doctors who are no longer practicing or even deceased pop up as "in-network" on dental insurance "find a provider" portals all.the.time. Most companies don't seem care to update or maintain their online portals if it benefits them to list more doctors than less.

I don't know how to fix this but it makes me so mad that this is a totally ok form of "doing business" in our country.

[idahome]

waverly: if your insurance is through an employer, call the HR team and ask the benefits person there to help. The employer likely worked with a benefit broker to obtain the benefits which means they have addition backend resources who can help find networked providers.

I currently handle benefits for my employer and have been on the broker side - trust me, I helped with situations like this (lack of network; figuring out how claims would process against deductibles; etc.) often.

Good luck!

[waverly]

Thank you all. I think I found a provider in both medical and dental. If that doesn't work out, I will circle back to insurance and employer health care broker.

[Bad Dingo]

Apr 25, 2024 9:15:52 GMT -5 waverly said:

When I reached out to the insurance to let them know that they had bad phone numbers for at least 3 doctors on their list of lets say 8 doctors and that 3 listed are in contract disputes, they let me know that they cannot update or correct their information because it is submitted by the doctors, so the doctors submitted it wrong. OK so continue to send out the wrong phone numbers to all your insureds then.

FYI, feel free to tell them that they are not following the mandates of the No Surprises Act: The No Surprises Act requires health plans to conduct an attestation process every 90 days to verify that their provider directories are correct.