Recently I decided I wanted to do something a little different, and announced on our Facebook page that I was doing free 30 minute calls for people who are considering TMJ surgery. I’ve now had most of these calls, and was really interested to see what the common threads were among the patients I talked to. Even though every one of these women were different, they did have several things in common that were frustrating them.
One of the common threads that came up in every call was INSURANCE.
Obviously this doesn’t come as a surprise to many of you, since insurance coverage is a common struggle for TMJ disorder patients.
We seem to face one of three scenarios:
1) We’re stuck in what I call “insurance no-man’s land” (it’s not medical or dental, no one seems to want to take responsibility for covering it),
2) TMJ disorder diagnosis and treatment (conservative or surgical) isn’t covered by our insurance at ALL,
or, 3) Diagnosis seems to be covered but insurance companies balk at paying for any treatment and try to deny all the claims.
Over the years, I’ve had many conservative therapies and many surgeries, as well as several insurance providers. I’ve also helped patients with their insurance issues (appeals, general advocacy, etc), so I’ve experienced and seen a ton of different insurance situations.
Here are my top 5 tips for dealing with your insurance company.
If you follow these, you’ll have less frustration because you’ll be more organized, you’ll have an understanding of what you’re dealing with, and you’ll know what to do next. Be sure to read to the end because I have a surprise for you.
1. Be familiar with (and understand) your benefits.
This tip is very important, because insurance companies often say no to claims JUST because they assume you have no idea what they should and should not cover. You might be surprised if you know how many people just back down and shrug, “oh, ok” and go on to pay for their treatments when their insurance company denies their care. You need to know what your coverage is, what it means, how to use it, and what happens if you do get a denial.
The best way to do this is to read your policy and all of the information that comes with it. If you have questions about terminology, Google is your friend! If you have questions that are more complicated, you might seek out someone (maybe your insurance broker or your human resources department) to help you make sense of the whole thing.
Specifically with TMJ disorder, you need to look and see what the coverage is in your plan (if there is any), as well as what they consider “experimental.” Read both your medical and dental policies, and ask questions!
2. During all phone calls, ensure you write down the call specifics.
Write down the date, time, person’s name, the purpose of your call, and what they said. Keep a running log of every communication you have with your insurance company.
If you live in a state that allows this, you might consider recording the call if you are confused with some of the terminology they use (check on the legalities of this in BOTH states before you do it). Either way, you want to be able to get a very clear idea of exactly what was said on the call when you read your notes months later.
See below for a handy download that will help you with this!
3. If they promise you anything, get it in writing!
After you’ve written down all of the above info, if the insurance company offers you anything, get this in writing via fax, email, or certified mail. You may not be able to do this with every single thing they promise you, but for bigger approvals (surgeries, for example), getting it in writing is important.
4. Be persistent, but know when you need to escalate.
You might have heard tips from others telling you to keep calling until you do get an answer. I agree with this in part, but I do think at a certain point that calling consistently will not help your case – it’s just a waste of your time. If you continue getting the same answer over and over, and you and your doctor think it is unjustified, you may need to escalate the case. The front line people that answer the phones are not really able to make decisions. Instead, keep escalating until you get to a person who CAN. This usually involves getting your doctor on the phone with their doctors.
Also, this means you need to know what the process is for escalation, so you need to know your policy (Tip #1!).
4. If you get a denial, make sure you understand WHY.
In my extensive experience with insurance and surgeries, I realized that many of my denials were not because they flat out were NEVER going to pay for my surgery. Instead, the insurance companies denied my claims based on other issues…codes being wrong, a piece of paperwork that is missing, etc. Before you pull out the big guns and start the appeal process, ensure you understand why you are being denied in the first place. If it is something simple, you can fix it and move on!
5. Get your doctor and his/her office involved.
If anyone is experienced in dealing with health insurance companies, it’s your doctor and his/her office staff. Often surgeons will have one person on staff who is a specialist in insurance and understands what needs to be done with each insurance company to get approval for treatments/surgeries. If you have been fighting the insurance company alone, a simple letter from your doctor stating “medical necessity” can make all the difference.
I know insurance coverage is a big barrier to a lot of you getting the diagnosis and treatment you need…
I want to make sure that you have all the tools you need to fight for the care you deserve. So, I have created a free worksheet that you can either fill out on your computer and save using Adobe Acrobat or Preview on a Mac, or you can print it out for your medical binder/folder. It will remind you to take notes during your call and record all of the important information you may need later.
To download the worksheet, click here and enter your email address.
(This way we can send you updates to the worksheet, new free stuff, and our newsletter, too.)