Medical Questions > Conditions and Diseases > TMJ Forum

TMJ and Medicaid

I'll try to make this not too long and get to the point, any advice would be much appreciated.

I'm on track for a jaw surgery which will pull my lower jaw forward and relieve much pain, difficulty chewing, and all the other complications that go along with tmj. But first I need my teeth straightened otherwise the surgery would not be possible.

I'm 22 which makes me just over the eligible age for medicaid to cover orthodontics. I've had about one year of braces, about 7 teeth removed, and a surgery to basically scrape scar tissue away to allow enough opening to be fitted for braces.

Due to insurance complications, I was unable to pay my old orthodontist and just went for a consultation with a new doctor.

I'm going to school full time and just don't know what to do. Do I have any leg to stand on as far as Medicaid goes? If my TMJ surgery is considered a medical necessity by the ENT surgeon, then how is the prerequisite of orthodontics not considered also a "medical necessity".

I've had this TMJ pain, along with JRA since about 3 years old, so 19 years later. Thanks in advance.
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replied August 8th, 2011
Thanks for responding.

The ENT Surgeon does believe I need surgery, and I don't doubt it.

Limited opening and daily pain. I've already had one surgery which was covered by medicaid. The only thing standing in my way now is the braces.

So frustrating.
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replied January 25th, 2012
Experienced User
I am going to chime in, here, on Medicaid. Mostly, because I am a US expatriate and I want to familiarize myself with the new "Obamacare" regulation.

I researched it, and, as a relatively neutral party who is on the outside looking in objectively at the Medicare point, it seems that:

1) If the physician/DMD/ortho is familiar with what Medicare covers and is willing to file with that entity on your behalf and, by law, is entitled to be reimbursed ... then you may be able to work with him or her on your medical situation.

You, as a patient, also must understand that Medicare/'caid/govt.-sponsored H.I. may drag its feet in reimbursing said practitioner(s), rendering it impossible for that person to efficiently run a business, or possibly even forcing a private practice bankruptcy or, let's hope not, a personal bankruptcy. If the reimbursement period is anywhere NEAR private insurance reimbursement time frames, then I believe you would be able to work with the practitioner.

2) Second point is: Does Medicare reject lawful claims made by a practitioner on a regular basis, even though the work is clearly covered by law? If so, then the doctor/dentist/orthodontist is clearly faced with having to "fight" for every Medicare patient in order to get reimbursed. There simply isn't enough time or money to do this, unless the dentist hires an interested healthcare attorney within some kind of dental community/co-op network pool that practitioners support with a collective fund to represent them so that other like-minded dentists within the same state of practice have this attorney to fight for the reimbursement of these Medicare claims on every rejected patient. Which is entirely possible in a larger state, where dentists would seek to gain an untapped medical resource for many practitioners, thus making it worthwhile for state and federal governments, patients, dentists to use this avenue.

3) I have no idea what the discrepancy is with the ratio of what Medicare reimburses vs. what private insurance reimburses, but you'd have to figure on common sense, alone, it must be a lot less. Like I say, I do not know. You can ask your ortho/dentist who could reveal this to you in good faith. (Why not?) Or see if an investigative medical reporter would like to pick up the "beat," as it's named in the profession. I am sure they would. Especially with the new Obamacare issues, which can be positive, if they are effective.

On a final note, for the practitioner who does not wish to fight for EVERY claim that is rejected (either by private insurance or Medicare/caid) that person is faced with the project of, quite literally, getting in touch with someone higher-up, let's say, the President himself, to get a foot in the door to lobby Congress and have this kind of claim (and clearly-defined related claims) be put on a bigger bill and voted on and passed through Congress. This has been done by a doctor who lobbied successfully to get with private insurance to get them to cover plastic surgery for breast cancer patients and the sometimes necessary breast symmetry operations for mastectomy --breast cancer-- patients. So, it can be done. I believe a mere 5 years in Congress is NOTHING compared to the years of suffering these TMJ patients are living with.

We can only pass our good work on from one generation to the next, and I do not see that America is getting itself out of its dire situation anytime soon. There will be more and more patients on Obamacare than we've ever imagined, and in the very near future, from what I understand.

The problem, here, is the kind of bill needed for the issue to "ride on," or be attached to... and the type of insurance being fought for. (Private vs. Medicare/caid). As I understand it, it is easier and less time-consuming to pass a bill that's related to private health insurance. Perhaps a group of interested dentists can move on to addressing Medicare/caid, at the same time. ...Which is entirely possible.

It is my understanding that over 50 million people in America are now on EBT/SNAP (Federal Food Stamp Program). I am sure it must be more than that, really. From what I've read, the Obamacare now extends its outreach to those in the exact same income bracket who qualify for foodstamps, and it is, in that case, based on income, not disability, alone. So you've got that. Automatic 50 million people (including students, who don't necessarily make any income) necessitating this Obamacare /Medicare insurance, as some universities now require students to find their own insurance outside of university healthcare plans, prior to their enrollment. If not insured, in all walks of life, you ahve to pay the "fine" unless you're in a specific income brackt, which we've already determined 50 million people AND MORE should be in, at this point. remember, states (especially California) is LOSING BILLIONS right now to unenrolled food stamps eligible populations. There is no shame in enrolling to get food stamps, especially with so many young, old, mid-career people OUT OF WORK, whose jobs which may never effectively return.

States are now noting that they are leaving BILLIONS of dollars in Federal monies on the table and LOSING this much-needed money by not reaching all eligible people for the SNAP program. In some states, people are actually able to use these food stamps at organic farmer's markets.

Don't you think with the ongoing recession and global economic depression, which we've not seen the worst of, would be an incentive to look this stuff up, build a coalition of practitioners, lawyers and interested lobbyists/patients and take control of this, thus making the state and federal govts. more money?

That would assume the practitioners get rightfully reimbursed and within a reasonable time frame/reasonable cash flow margin.

essentially, what America is becoming is a slave to our government in ALL aspects of life. Gone are the days of studying to be a doctor or lawyer TO MAKE GOOD MONEY. At this point, the educational costs are so high that the debt-to-income ratio is so off-balance, that once graduation happens, essentially we may be making about the relatively "same" income, with some of us having more expendable income due debt instrument deferments, or less educational expenses when it's all said and done.


It's time to work within the system to change it.

Otherwise, you only have the alternative of a thing such as "Health Democracy," as written about and started by Paul Glover ...which is entirely possible within NM dentistry and orthodontic practice. And even co-operative banks that cover such democracies.

All the best to you!

My situation is not getting any better, so I am staying on top of this with you....
Peace
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replied January 26th, 2012
Experienced User
some factual information I found out pertaining to Medicare/TMJ: (2009 edition, state of Michigan):

Medicare Advantage private fee-for-service
Temporomandibular joint appliance
January 1, 2009
Reimbursement
The maximum payment amount for the temporomandibular joint appliance benefit is available in a separate
document, BCBSM Medicare Advantage - Additional Benefits Fee Schedule. The provider will be paid the lesser
of this allowed amount or the provider’s charge, minus the member’s cost-share. This represents payment in full
and providers are not allowed to balance bill the member for the difference between the allowed amount and
the charge.
Member cost-sharing
* Deemed providers must agree to collect from the member only the cost-sharing amounts described in the table
below. They may not otherwise charge or bill the member.
* If the member elects to receive a noncovered service, he or she is responsible for the entire charge associated
with the noncovered service.
For detailed information about BCBSM Medicare Advantage member’s benefits and cost-share, review the group
plan’s Summary of Benefits. The chart below identifies members with TMJ appliance coverage.
Group name and number
State of MI
Retirees
Troopers
81820
State of MI
Retirees
Nontroopers
81821, 81828
Billing instructions
1. Bill services on the CMS 1500 (8/05) claim form or the 837 equivalent claim consistent with the local Blue Cross
Blue Shield plan direction.
2. Use the Medicare Advantage private fee-for-service unique billing requirements.
3. Report CPT/HCPCS codes and diagnosis codes to the highest level of specificity.
4. Report your National Provider Identifier number on all claims.
5. Submit claims to your local BCBS plan.
6. Use electronic billing:
a. Michigan providers:

-- A copy of the BCBSM EDI Professional 837/835 Companion Document is available at:
http://www.bcbsm.com/pdf/systems_resources _prof_837_835.pdf
b. Providers outside of Michigan should contact their local BCBS plan.
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replied January 26th, 2012
Experienced User
if you google tmj and medicare, it is possible to see the confusion the dental care practitioner is met with -- concerning TMJ, and how little control the practitioner has over his or her collections (monetary collections process) in the field of medicine.

It serves these practitioners best to consider a 'health democracy' concept since their work is not widely accepted within social/medical constructs, as of yet, and most Americans currently live within the concepts of what healthcare/dental care is provided to us.

Awful.

And to imagine, being a professional and having to rely on a government or corporate entity to repay me for work that I complete and deeming it necessary or not.

No wonder concierge doctors, even dentists, are the fashion.


Old News (2004)

WHERE DO DENTISTS SEND THEIR OPT OUT AFFIDAVITS? - 07/27/2004
As of February 8, 2004, dentists can now enter into private contracts with Medicare patients, which preclude those dentists from having to bill Medicare and accept its fees for covered services. It is important to remember that dentists are able to charge their full fee for routine dental services that are statutorily excluded from Medicare even if they do not opt out of Medicare. Opting out merely protects dentists from Medicare fee limitations for dental services that may be covered by Medicare. Some of the services that are typically performed by dentists that may be covered by Medicare include TMJ appliances, sleep apnea appliances, brush biopsies, surgical biopsies, and extractions prior to radiation therapy. Dentists who perform these services on Medicare patients are required to accept Medicare fees unless they have specifically opted out of Medicare.

When a dentist opts out of Medicare no services provided by that dentist are covered by Medicare for at least two years and no Medicare payment can be made to that dentist. Additionally, no Medicare payment will be made to a Medicare patient for items or services provided directly by a dentist who has opted out of Medicare. It is also important to note that a dentist cannot choose to opt out of Medicare for some Medicare patients but not for others--or for some services but not for others. It's all or nothing. After the two year opt out term expires, a dentist can elect to return to Medicare or opt out again.

If a dentist decides to opt out of Medicare, he/she must send an opt out affidavit/letter to his/her local Medicare carrier and enter into a private contract with each Medicare patient, prior to rendering dental services. A sample opt out letter and private contract can be found in our May/June 2004 newsletter. You can obtain the opt out address for your local Medicare carrier by going to [url deleted


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