Ch 12: Self Advocacy · Step 4: Cutting Costs

How To Get That Thing You’re Covered For

If I were able to give only two tips, it would be:

  1. “record all expenses” and
  2. demonstrate your eligibility.

The second is reflected in the following true story.

In amongst a host of atypical experiences, my child is missing some teeth. They didn’t develop in utero. As a result, he requires some orthodontic care. Even though bones are part of the body, they are often not covered in our “free medical” system. I am responsible for a bill of $9000…unless my obscure insurance plan will cover it.

MaleSkeletonsitting1.jpg
Skelly casually awaits the day bones are deemed part of the body.

 

We were almost damned before we started. The orthodontic office said, “We’ll submit some documents and hope the insurer offers to cover it. In similar situations in the past, they haven’t. They have a policy, and a panel that looks at the file and makes a decision, period. None of us have any say.”

Whoa, Nellie. That’s not really how it goes. It actually goes like this:

  1. There is a law. A concrete, set-in-stone stipulation as to what circumstance is covered.
  2. Regardless of all office policies, and who is hired to look at the documents, the insurance department is required to honour the law.
  3. If the insurer disregards the law—or loosely interprets the law in their favour—the client may challenge the decision.
  4. If the client challenges it, the matter goes through an appeal process, and the client may well win the coverage.

I begged the orthodontic staff to submit nothing until I had had a chance to look up the law, precedents, etc. The more effectively your case is presented from the get-go, the higher the chance it wins at initial submission or appeal.

Alas, I was fairly certain the office wasn’t quite hearing what I was saying. The orthodontist staff remained certain that coverage was random, based in unidentifiable factors, a matter of fluke—like a lottery ticket! I feared the specialist would, then, proceed to submit documents without consideration of what information was actually relevant.

I cancelled my plans for the rest of the day, headed straight home, and began my work. Within four minutes, I had located the law that applies. Within another three minutes, I had located a very similar case that had gone to appeal and won. I supplied these to the specialist.

Now, there are things I cannot decide nor control:

  • I do not control what the law currently is and states.
  • As a non-doctor, I cannot know or declare that my kid’s skeleton does or does not meet the medical criteria.
  • I cannot control what a third party does or does not bother to submit and when.

What I do know, however, is some administrative law. I have learned the process for applying for the coverage we are purported to have. I know what we are allowed to submit in this initial step. I know when the insurer must provide a decision by. I know how many days I have—after that decision is communicated—to initiate an appeal. I know what sources I may draw on to bolster our appeal.

In this case alone, such information has the potential of eliminating $9000 in out-of-pocket costs.

I may or may not win this coverage—that depends on whether my kid’s face does indeed meet the legal criteria. But given how many times I have won tens of thousands of dollars, taking these timely steps is well worth it to me. Even if I lose, it will have been excellent practice for our next pitch 🙂

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5 thoughts on “How To Get That Thing You’re Covered For

  1. I have a question. My SO went to a dentist who insisted on a cleaning before ever seeing her, and once the initial exam was done sent her to one of his office ladies to schedule a follow up. The cleaning and exam xrays etc ate up 1500 of her 2000 dollar coverage. The office lady insisted that she schedule a single appt to get all the remaining work done at once, to the tune of 8000 dollars. She left without scheduling, because that sum is not in our budget. How do we more effectively convey that we can afford smaller steps in treatment, but can’t pay even with care credit, for that large of a procedure?

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    1. Hi SEAKSR,

      So sorry you had this experience! I find dental administration some of the most difficult to navigate, so I do understand.

      I’m used to medical services costing a LOT, and yet $1500 for cleaning and exam xrays seems like an enormous amount. I’ve never been billed that.

      First, I would use RateMD to find out others’ experiences of this dentist and others in your area. Then I would take one of two paths:

      PATH ONE

      1. Ask your current dentist for a printed, detailed breakdown of that bill. Also ask if they offer reductions in fees for immediate payment, or bill lower amounts based on coverage. (For example, my counsellor charges me $131 per hour and my insurer $173 per hour.)

      2. If the dentist has excellent client ratings and testimonials, and those match your own experience, consider staying with this one.

      3. If you stay with this one, write a letter to the dentist saying what you can manage. Watch for a response. If there isn’t a response within two weeks, move on. If there is an unsatisfactory response, move on.

      4. If the response indicates that the dentist understands what you are saying and is open to what works for you, work out a payment plan in advance.

      5. Ensure the plan is signed by both parties and keep a copy, so that you can show it to the administrative staff as needed.

      PATH TWO

      1. If the dentist has poor ratings, or you know your experience to be sufficiently poor, select a different dentist -one with high client satisfaction.

      2. Most of us find that when we see four different dentists, they say four different things about work needed. One declares you need a filling, one says everything’s great, another recommends expensive treatment, and so on. When any medical professional is recommending invasive, difficult, stressful, or expensive treatment, seek a second opinion. (This is what I did regarding my son’s mouth care. They had similar assessments, but the first only told me the first year’s cost and the second told me the full treatment cost. I appreciated and valued the honesty of the second. The second also offered a payment plan, offered to apply to my tricky insurer, and offered to write a letter of recommendation to charities that help with specific medical issues, if necessary.) Yes, it can cost another, say, $150 for that appointment, but if a second or third doctor says a procedure is unnecessary or problematic, you’ve saved much more!

      3. Before having any appointments, ask for a copy of the office’s fee schedule, payment terms, and payment plan options. Also ask which insurance programs they accept. For example, my child has two points of partial coverage -some dentists accept those and some do not. Selecting a dentist that does saves us thousands of dollars over the years.

      4. Write a letter to the dentist outlining what you are able to pay and at what intervals. Ask her office to sign it. Keep a copy.

      SEAKSR, I hope this is helpful!

      Thanks very much for your question.

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  2. SEAKSR – I recently had cleaning and dental xrays done, and it cost me $214. You were definitely overcharged. They are lovely people would absolutely be willing to work with you on a schedule/plan. If you are in Victoria BC (or anyone in Victoria BC) I highly recommend Dr Joan Watt, who has a practice at Shelbourne and Mackenzie across from the University Heights shopping center.

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