Jaw surgery is $ 27,119 off a man’s budget | lifestyle

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For years, Ely Bair dealt with migraines, jaw pain and high blood pressure until a dentist recommended surgery to realign his jaw to get to the root of his health problems.

The solution would involve two surgeries over a couple of years and wearing braces on your teeth before and between procedures.

Bair had the first surgery on the upper jaw in 2018 at the Swedish Medical Center, First Hill Campus in Seattle. The operation was covered by his Premera Blue Cross plan, and Bair’s hospital costs were $ 3,000.

In 2019 he changed jobs, but was still insured with Premera. In 2020 he had the planned lower jaw surgery in the same hospital where he was treated for the first time. The operation went well, and he spent one night in the hospital before he was released. He healed well and began to see the benefits of the operations.

Then came the bill.

– The patient: Ely Bair, 35, a quality assurance analyst. He has a Premera Blue Cross health plan through his job at a biotech company in Seattle.

– Total Bill: The Swedish Medical Center billed Bair $ 27,119 for the second surgery in July 2020. This was Bear’s share of the negotiated rate after the hospital deducted $ 14,310 from the fee. His insurer paid $ 5,000. Bair owed the surgeon and anesthetist additional bills.

– Service Provider: Swedish First Hill Campus in Seattle, part of the largest non-profit healthcare system in the Seattle area connected to Providence, a large Catholic healthcare network.

– What gives: Bair encountered two insane health system pitfalls here: he expected his new plan to behave like his previous one from the same insurer – and he expected his mouth to be treated like the rest of his body. None of the common sense concepts seem to be true in the American healthcare system.

Typically, large corporations like Bair’s employers take out self-insurance, which means they pay for their employees’ healthcare bills, but use insurance companies to maintain provider networks and handle claims. When Bair switched jobs, his insurance coverage changed, even though both employers were using Premera. Bair paid $ 3,000 for his first surgery because that was the maximum out of his own pocket that he had from his previous employer who covered oral and maxillofacial surgery.

Bair assumed that the cost of the second part of his treatment would be similar if he used the same hospital and insurance carrier. Bair’s oral and maxillofacial surgeon – the same doctor who performed the first procedure – checked Bair’s benefits through his insurer’s online portal and thought they were covered. Premera also sent his doctor’s confirmation that the second procedure was medically necessary.

About three months after the operation, Bair was shocked to receive the huge hospital bill – about $ 24,000 more than he expected.

When he called Premera, he learned that his new plan has a lifetime coverage limit of $ 5,000 for reconstructive jaw surgery known as orthognathic surgery, which is sometimes viewed as dental rather than medical. His doctor said no information was recorded on Bair’s services when the practice reviewed them through an online portal. Premera told Bair he should have known about the limit because it was listed in his detailed, printed 86-page member benefits brochure.

The Affordable Care Act of 2014 removed lifetime and annual coverage caps for treatment categories such as prescription drugs, laboratory services, and mental health care. While the ACA lists broad categories of what qualifies as “essential health benefits”, each state decides which services fall into each category and what scope or duration must be provided. Bariatric surgery, physical therapy, and abortion are examples of treatments for which coverage under this ACA provision can vary widely by state. Orthognathic surgery is not seen as a major health benefit in Washington. It is sometimes done for cosmetic purposes only. In plans, surgery is also sometimes considered part of orthodontics – which is often associated with limitations in coverage. But for Bair it was a clear medical need.

Without an ACA orthognathic surgery requirement, premera and self-insured plans may offer different benefit levels and may impose annual and lifetime caps.

Premera spokeswoman Courtney Wallace said Bair had moved from a plan with his former company that didn’t have a lifetime maximum to a plan with a maximum lifetime benefit of $ 5,000.

Martine Brousse, a patient advocate and owner of AdvimedPro, who helps patients with healthcare billing disputes, said Bair acted appropriately by visiting a doctor and hospital on his health plan network and asking his doctor about his insurance coverage.

She said Swedish should have told him how much he would have to pay before the operation – which was scheduled weeks in advance. “This is a failure of the hospital,” she said.

Sabrina Corlette, co-director of the Georgetown University Center on Health Insurance Reforms, said it wasn’t fair that his first employer paid for his surgery but the second employer didn’t. She said the $ 27,000 bill seems excessive and the lifetime limit of $ 5,000 is very low. “Essential health benefits have a really important role to play, and when there are gaps or holes, people can really get hurt,” she said.

– Solution: Bair’s doctor told him that the hospital costs were at least three times the Swedish costs for uninsured patients for the same operation. Bair said Swedish offered to pay the bill over two years but made no other concessions.

Swedish wouldn’t say why it didn’t check Bair’s insurance benefits before surgery or let him know he was facing a huge bill even though he was insured.

“Hospital prices are complex and nuanced,” Swedish officials said in a statement. Bair’s bill “covered all of the care he received, including specialized services and skills, equipment, and operating room time. He had jaw surgery that had a maximum benefit from his insurer of $ 5,000. He was charged the balance that was not covered by his insurance. “

The hospital system said it also has an online tool that generates estimates tailored to patient care and hospital choice.

However, the online tool did not bring anything to the term “orthodontic surgery”.

Bair appealed three times to Premera to reconsider his decision to pay only $ 5,000 of the cost of his trial. But the insurer refused everyone, saying he had exhausted his lifetime benefit for orthognathic surgery and he was responsible for any additional treatment. When Swedish did not want to cut its costs, it filed a complaint with the prosecutor in December 2020.

A few months later, Swedish Bairs reduced the bill from over $ 27,000 to $ 7,164.

“Neither the patient nor his doctor knew about this limitation of coverage before the procedure, the surgeon has worked on behalf of the patient to lower the bill,” said the hospital to KHN in a statement.

Bair agreed to pay the lower amount. “The bill is at least a much more manageable number than the financial ruin of $ 27,000 would have been,” he said. “I’m just looking forward to closing this chapter and moving on.”

His surgeon, who helped him battle the hospital bill and limited insurance coverage, reduced his bill from $ 10,000 to $ 5,000, Bair said.

Bair said his employer, Adaptive Biotechnologies, is considering lifting his $ 5,000 lifetime limit on the procedure if medically necessary.

Since the operation, Bair said he had much fewer migraines and that his high blood pressure had dropped. “I feel a lot more energetic,” he said.

– The takeaway: In the event of a planned operation, talk to your hospital, doctor and insurer about the amount of the bill you are responsible for – and have it submitted in writing before each procedure.

“In theory, you should be able to rely on your provider to confirm your coverage, but in practice it is in your best interest to call your insurer yourself,” said Corlette.

Although the ACA has removed lifelong and annual coverage caps, this only applies to services that are deemed essential in a patient’s condition. Be aware that certain surgeries – such as jaw surgeries – are in a gray area; Insurers may not consider it a necessary medical procedure or a medical procedure at all. Corlette said health plans should notify patients when they reach their lifetime or annual limits, but that doesn’t always happen.

Also note that while your insurance provider stays the same after you change jobs, your benefits can be very different.

Kudos to Bair for being a proactive patient and reaching out to the Attorney General – which got him a positive outcome.

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Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill that you would like to share with us? Tell us about it!

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(KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health topics. Along with Policy Analysis and Polling, KHN is one of the three major operational programs of the KFF (Kaiser Family Foundation). KFF is a not-for-profit organization that provides health information to the nation.)

© 2021 Kaiser Health News. Distributed by Tribune Content Agency, LLC.


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