well it depends on the state and the doctor----i wouldnt even bother with insurance--they most likely wont bother with it---do you have a surgeon lined up???? give them a call or when you go in for a consult---ask--they usually give you and estimate up front---then when they get in there it may cost a little more depending on what the y find
What kind of advice is that?! Don't even bother with insurance?
Do you realize that I cannot afford this? Do you realize that insurance has no right to deny such treatment if it is found to be medically necessary?
Insurance companies have long been over using (abusing) their powers in denying people their treatment. Even if the state has no law mandating coverage for particular disorder treatment, for example such as MS mantainance therapy, each individual claim decision can be fought and argued against. The least thing that insurance companies want is patients who are upset, and who go to state's attorney general office to complain. After enough complaints are filed, somebody finally does something.
Thank goodness for Obama Care. This is coming into effect in stages. One of the recent phases that currently went through is now insurance companies have to spend at least 80% of what they take in on paying insurance claims vs. paying it out in bonuses and higher salaries for those up top. You are correct since it is medically necessary they must cover it how much depends upon the insurance.
I'm in the process of looking into this myself before they lower what they do cover. I was trying to put off the surgery but financially, I might not be able to. Mine needs to be preformed in two stages, the bottom & then the top.
Aetna U.S. Healthcare, the insurance carrier for DuPont, denied coverage for the surgery on the ground that there were more conservative and medically appropriate treatments available, such as arthrocentesis or arthroscopic surgery nevertheless went ahead with the arthroplasty surgery and covered the
cost of $9,829.05 herself.
She then brought suit against DuPont in federal district court.
The court found that the record before the administrator (Aetna) and, on appeal to the DuPont Medical Care Plan, supported the denial of coverage for Stratton's TMJ surgery. Stratton appealed, contending, among other things, that Aetna had paid insufficient attention to her claim.
The circuit court found that the record was "detailed and comprehensive" and that DuPont and Aetna "took many steps" in considering Stratton's claim, from inviting additional information and medical history by Stratton and her previous treating physician to reviewing the TMJ post-operative report and having three physicians, one of whom was not involved in the original decision, review the information submitted before finally denying Stratton's request.
As the appellate court observed, Stratton had not previously attempted either arthrocentesis or arthroscopic surgery, both of which are less invasive treatments than the arthroplasty she chose to undergo and both of which Aetna physicians had recommended in lieu of the arthroplasty. The Third Circuit then pointed out that it was not its role to decide which of the three procedures was best tailored to Stratton's case, and declared that "a review of the record shows that DuPont acknowledged and considered that the more conservative treatments had not worked for Stratton in the past and that its suggestion that she undergo less invasive procedures was not based on oversight."
Finally, the circuit court rejected Stratton's argument that Aetna, DuPont, and the district court had failed to accord sufficient deference to the opinion of her treating physician, who had recommended the arthroplasty. As the Third Circuit pointed out, last year, the U.S. Supreme Court, in Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), held that "plan administrators are not obliged to accord special deference to the opinions of treating physicians." It concluded that Aetna's physicians had not arbitrarily refused to credit Stratton's doctor's opinion but simply had disagreed with his recommended treatment. Accordingly, the appellate court affirmed the trial court's decision in favor of DuPont. [Stratton v. E. I. DuPont de Nemours & Co., 363 F.3d 250 (3d Cir. 2004).]
Comment: A court that scrutinizes a coverage decision by a plan administrator should have a great deal of information to review. Decision makers therefore must ensure that their files are complete and that their decisions are carefully reasoned and explained. If a dispute does reach court, the administrator will seek to have the court decide that the denial of benefits was "supported by the evidence in the record."
So yup, just like I've read somewhere before, it goes around 10K.
The cost will depend on what the actual procedure is done. Your surgeon may say we're going to do this, however when you are in surgery they may decide to take a detour or add something.
Best route to take: Have your surgeon's office contact your insurance company and they will be able to see if this procedure would be covered and what your co-insurance / co-pay and / or deductible would be. This is generally an estimate of what your cost would be as if there are other claims ahead of this one that get processed then you might not owe the deductible for this claim. Just an FYI.
Also ask your them what their self-pay rate would be. You may find that by paying for it yourself is cheaper than what you would owe if it was filed to your insurance company. Not likely but it does happen.
Also note that not only would you get a bill from your surgeon but also from the hospital / surgery center / anesthesia, etc. If they are involved in your care then more than likely they will bill for their services unless it was included.
I had arthroscopic TMJ surgery on my left joint. My insurance covered 100% of it. From the statements I received it would appear to cost about $10,000 USD. My wife is a registered nurse and her hospital twisted the insurance companies arm until they were forced to pay it all.
Cost Breakdown of Billing submited to my insurance.
I just had TMD cartilage reseating authroscopic surgery done, outpatient moderate complexity (not too complex took 45 minutes) and the breakdown is; (without naming any party involved, myself, medical staff or hospital, nor my insurance company)
Office visit pre-surgery : 130.00
MRI (series of three): 7189.07
Pre-opp Lab tests: 280.90
CRNA (nurse anesthetist): 485.61
Oral surgeon : 2200.00
Hospital (nurses, opperating suite, recovery unit, medicines not covered under anestiatesia sterilization and use of equipment, ect ect. ) 26,177.34 ÃÂ
The grand total of an hour to hour half procedure (not counting tests and set-up) is 37,033.84
My total out of pocket 2154.00 (I have a deductible of 2500 a year just to be able to afford the premiums)