General chatter - Peradontal Disease ?
08-09-2007, 12:23 PM
Okay so maybe I'm spelling it wrong, but it is a disease of the gums.
My husband is 36 and he has this. He has always been great about taking care of his teeth. He brushes 3x a day, he flosses every day, spends way more time than I do on his oral hygene. The dentist always gives me rave reviews and says great teeth! doing a great job flossing! yet, I never floss and am always in a hurry when I brush.
SO anyway, the question for anyone out there is about INSURANCE.
My husband works for a huge company (world wide company), we have great insurance, but apparently our dental sucks. He needs surgery to replace his gums! Half of his mouth will cost about $4000 and dental will only pay $1700, leaving us to pay the rest. That is just half the mouth. We tried to file a claim with medical to see if they would pick up the difference. Don't know why 100 people over at medical need to get involved in processing the claim. Depending upon who you get over there, you get a different answer. It would be so much easier to have one contact. If he does not have this procedure his teeth will eventually fall out !
He is so young!!! Any tips or ideas on how to proceed? If medical does deny the claim then we will file an appeal.
I just keep thinking of MICHAEL MOORE and SICKO....haven't even seen it yet, but know it's about the healthcare industry over all.
Thanks for any advice!
08-09-2007, 12:45 PM
While I don't have any specific help, I'd think that your medical insurance should cover this if you request it. This is major surgery! My dad had it done (in stages--I think he went every 2 months or so for part to be done and I think it took 6 or 8 sessions to complete).
Be aware! This is VERY painful surgery. They take skin grafts off the roof of the mouth and graft them onto the gumline to restore the gumline. Anyone who has burned the roof of their mouth knows how tender it can be--think about having a huge section shaved off! My Dad couldn't eat for a couple days after each surgery.
BUT the alternative of losing one's teeth makes it 100% worthwhile.
Anyway, since it is surgical, check with your insurance and see if they'll consider covering it. It has to be done by a specialist so they might.
08-09-2007, 12:48 PM
I don't know the answer but I have a couple things that maybe you could look at -
1) is your current dental insurance the best that you can get with the company? My company has 3 dental insurances, the first 2 aren't great but are good for people who need standard work done. The third covers a lot more. I knew I needed dental work done this year so I temporarily switched to the better insurance.
2) Does your husbands company have a health care spending account? I believe you are able to deduct medical expenses from your taxes that exceed 7% of your income but a health care spending account is another way to avoid paying taxes on medical expenses. A health care spending account takes pretax money from your paycheck and puts it into an account in which you get reimbursed for medical expenses. For me, I put $1500 into the account this year and got reimbursed for my dental bills from this account. For someone in the 25% tax bracket, it would basically mean a 25% discount on medical expenses. The only caution is that you need to use up the amount within the calendar year but if you get an estimate from the dentist on the total cost, you could set aside that amount.
08-09-2007, 01:26 PM
Hi! My mother had the procedure done when she was only 55 and is fastidious about oral hygiene, so periodontal disease often occurs as a result of a genetic predisposition. Her surgery was done all at once, not in stages like Allison's dad, so maybe your husband can aim for that if given a choice. I'm sorry I don't have any insights into the insurance side of things but I did want to share that my mom is so happy she doesn't have to wear dentures anytime soon. :)
08-09-2007, 06:12 PM
Thanks everyone for all the info:
He has been seeing a dentist, then 3 mos later the periodontist, 3 mos later a dentist, 3 mos later a periodontist. He has done this for 10 yrs. So regardless of his good habits, he does need the procedure. Luckily they wont take skin from him, they are going to use synthetic so that is good, but they said he won't be able to talk or should not talk for a few days after the procedure.
You'd think medical would pick up the difference but it has been a major arguement for me with the medical. I think our dental is the best but I don't know about that spending acct, I was never good with that stuff. As far as tax brackets my husband is a scientist and makes a lot of $$$ so we're in the highest tax bracket.
Once we have the DECLINE in writing from the medical we will appeal and I may contact the states office but forget how to contact them. Isn't there a commissioner of some sort?
It is major surgery and without it , his teeth will fall out.
Yet if he had a car wreck, it would be covered. I told him to back the car out and hit the mailbox ! LOL, if he had cancer in the gum, that would be covered but not this.
We do not have the final word but am just trying to figure out my game plan. His HR department is of NO help whatsoever.
They are already giving up and saying "nope".
This is a clause from our insurance:
for treatments, including hospitalization and anesthesia, associated with temporomandibular joint syndrome (tmj), teeth, dental x-rays, braces, implants, services, supplies and appliances related to dentistry or any other dental processes including orthognathic (jaw) surgery and surgery relating to teeth and/or the bony supportive structure of the teeth, except as specifically covered under the Plan
This does not say "gum", so I don't know if "gums" fall into the above or not. However, it says "except as specifically covered under the Plan".
So then over under THE PLAN, it says this:
The Plan covers services and supplies needed for reconstructive surgery to improve the function of a body part when the malfunction is the direct result of birth defect, sickness or surgery to treat a sickness or accidental injury. It also covers reconstructive surgery to remove scar tissue on the neck, face, or head or reconstructive breast surgery following a medically necessary mastectomy.
08-09-2007, 07:59 PM
Can this procedure be done by someone else other than a dentist? When I had my wisdom teeth surgically removed an oral surgeon did it and I believe it was covered under medical not dental. Ask your dentist and peridontist about their experience with insurance on this, they should be a big help. I know with my insurance if I have surgery the doc has to send in some break down of the procedure and cost to the insurance and they respond back. Have they done this as a medical not dental? Hope this helps some. (dental insurance sucks, I had a crown and rootcanal that was $3,000 and I had to pay $1,500 of it!!!!)
08-09-2007, 08:08 PM
2bthinagain - I would definitely ask your husband to see if his company offers a health care spending account. If you are in one of the highest tax brackets, it will definitely help you, as I said it is basically allowing you to pay for medical expenses before the money is taxed. Effectively giving you a discount based on your tax bracket. If your tax bracket is 35%, then you get a 35% discount basically. Also check on the dental insurance to make sure it is the best option.
08-09-2007, 08:34 PM
Can your denist maybe recommend someone who does pro-bono (sp?) oral surgery?
Or maybe you could speak to their billing office and see if there is a resonable payment plan you could set up?
I realize this is surgery and you want to have the best for your DH but you could maybe look into your local Community Action. Mine in my area has a Dental Office and does it on a running scale based on the cost of the procedures and your income.
Lastly, I have a local community college that offers dental work at fraction of the cost-now I'm sure they don't offer dental surgery but maybe they know dental surgeons/specialists who would do this procedure for your DH and work something out for the billing.
Good luck-it may take some footwork but I'm sure this will all work out. :crossed:
08-09-2007, 09:40 PM
vealcalf - thanks for the idea, but no way would my husband go someplace where the discount is so huge...he'll think they are just practicing on him, and he wants "the best" to work on him. I doubt anyone would step up to do pro bono if they knew he was in the 6 figures income.
The dentist office is trying to work with us the dental insurance is paying a percentage but the medical should pick up the balance. The insurance companies just make it SO difficult that they want people to give up trying I guess. Their first response is always DENY DENY DENY the claims.
But I will keep fighting and do an appeal if I need to.
I know there is a State Insurance Commissioner of some sort, I need to find the number for our state and maybe they can help too.
I just don't see how they'd rather his teeth fall out. And who has time to sit and make fights like this? Hours on the phone while the kids don't have my attention that is what angers me more. Insurance should be SO much simpler.
08-09-2007, 10:49 PM
2Bthinagain ~ All I know is I had to pay for everything over my dentist deductable several years ago. It wasn't as much as your DH's is but close. Mine was hereditary accelerated by being a previous smoker for years. I will say I had absolutely no pain or discomfort. I remember my mom being in tremendous pain and agony, years ago, in the early 70's, probably like ALLISON'S dad. When I told her I had to get it done she just "lowly" screamed Oh GOD, Oh GOD...because she remembered the pain and didn't want it happening to her son....she IS NOT one to do something like that!
She was so relieved..AND ME TOO!...that there wasn't any pain.
Good luck to your husband...yep me too...4 cleanings a year...dentist...periodontist...
Oh, and I now need 1 tooth area re-done...one small area = $1,500!
08-10-2007, 08:56 AM
EZ - glad to know it wont' hurt as badly. I think he was looking forward to not talking for a couple of days! LOL
08-10-2007, 09:37 AM
2b - Be glad the insurance will pay for some of it. My insurance pays $25 for cleaning and that's about it!
I started a flexible spending account ( different than a health care spending account) 2 years ago so I would have money to pay the dentist. You might want to check on that.