If you've ever seen Ethan grin or laugh, you've seen his "snaggle-tooth" as I call it. His top right front teeth came in fused together. We took him, at the pediatrician's suggestion, to a pediatric dentist a few months after they came in to see if there was anything we needed to do to help prevent decay or any other problems. We were told that the obvious, brushing, was the best prevention but that because of how the teeth were formed (3 teeth were involved), it may not be possible to prevent decay.
Well, Ethan loves brushing his teeth but despite this, the snaggle-tooth became decayed. We took Ethan last June (ish) to our dentist for his first cleaning and then referred us to a pediatric dentist (the same one we'd seen before actually) to treat this tooth as he said they'd most likely have to use sedation and while he has done sedation dentistry, he wasn't expert enough with young children and thought we should see a specialist. When we got the estimate from the dentist, even with the insurance, our portion for the deposit alone was 300 bucks and then at least 100 more after this. We hadn't known we would need to do anything this involved when we registered for benefits for the year so had a lower level coverage on dental insurance and not enough in an FSA to help make those payments. So we opted to wait until the first of the year and plan ahead to get better insurance and enough in an FSA to cover it. The appointment was to be in late August anyway, so we reasoned that a few more months would have to be ok.
Fast forward to this year - the dental carrier changed as did the available plans. We now have Aetna Insurance with a DMO plan. We've never had a DMO or HMO so didn't really know how it worked. When we signed up, we had to pick a provider. We knew we'd need this treatment for Ethan so looked for a pediatric dentist but couldn't find one listed in the network so we chose a dentist to be our family dentist (the guy we used last year, who we really liked, was unfortunately not an option under this plan).
At the first of the year, Steve called Aetna and told them he was looking for a pediatric dentist for our 3 year old and didn't see one listed in our Network. They told him there isn't one in that network in a 40 mile radius, so they could give him an authorization code for this particular pediatric dentist (not the one we've seen before). Note - AETNA gave us the name of the dentist and that was it - use this authorization code. We assumed that meant, they adjusted Ethan's provider to this dentist using that authorization code. We scheduled an appointment and took Ethan yesterday.
We really liked this dentist yesterday. In fact she told us some new things about Ethan's teeth and that his teeth aren't just fused but he actually has a fusion & a gemination (sp?) which means 2 teeth fused together and then one of those teeth also formed like a siamese twin (which is why it looks like 3 teeth fused). She also told us he's got a problem with his bite that is going to cause problems that will need to be fixed in a couple years (not when he's older - I got the impression she meant before he gets his permanent teeth) to prevent further complications. They also did the teeth cleaning and gave us the treatment plan to do a double pulp-ectomy (meaning they have to clean the decay out of both of the fused teeth) using a liquid sedative they'll mix with sprite and have him drink. This won't knock him out but will calm him enough that they can do the procedure. They even gave us the print out showing what Aetna would pay, what we would have to pay, etc. Good news - our portion is much less than it would have been last year and we have enough in FSA to cover all of it.
When we left though, I called Aetna because the print out also showed the sedative portion wasn't covered. That had been the case last year, too, but when we checked with MetLife, they said for a 3 year old the sedative is medically necessary so it would be covered. I called Aetna to see if the same was true. This started my 75 minute ordeal with insurance - over 3 separate phone calls. The first lady was very polite - she looked up the info and said that the codes they'd used are not covered but that more potent sedation was - like IV, etc that knocks you out fully. I questioned that and she said that none of it was firm yet because it hadn't been approved. I was puzzled as I was looking a print out saying this was a quote - not an estimate - of what my costs would be. She told me that it would need to be pre-authorized. I then asked how I would have known that had I not called about something else. She said I wouldn't have but the dentist should have if they were in the network and then started looking up our history. She asked who referred us to this specialist. I told her Aetna had - she said Aetna can't refer us to a specialist, that our primary care provider had to do that - our dentist listed on our card. I then explained that Steve had called and they had authorized us to go to this dentist because there wasn't a pediatric dentist in our plan. She said that wasn't an authorization to change our primary care dentist as you can't choose a specialist as your primary care dentist which is why none were listed when we first looked. She asked if we had an authorization code, etc, and I had no clue because Steve had made the call and he was in a store with the boys at this point. I told her I'd need to discuss with Steve and would call her back. She said she'd note our conversation in the file so when we called back anyone could review our status. She was VERY polite through all of this.
I then talked to Steve and found out that he did have a code but that he thought that was to use this as his dentist now but that he had given this dentist the authorization number when he made the appointment so they should have it. Armed with this info and back in the car to be able to ask Steve any questions that came up, I called back. I got someone who was the exact opposite of polite but I'll keep the language G-rated. I explained the scenario and that we do have an authorization code (the previous lady had said we would need that to submit the treatment plan for authorization). This lady starts right up with saying that authorization code was valid for the consultation only and that we would have to go back to our primary dentist for another referral in order to get the treatment authorized and before we can have the treatment. This baffled me - we'd need to go back to a dentist we'd never seen before twice more before getting his teeth fixed? How is this helping Aetna exactly as we pay nothing at all to see "our" dentist - but they'd get a bill? I asked why we couldn't just use the authorization code we had already & have the dentist fax that for approval of the treatment. She snidely says, "because that's not how a DMO works. You have to go to your preferred dentist before each visit to a specialist." OK - but we didn't go to one before the first visit - you all authorized it because we already knew what treatment we needed? This went back and forth for 15 minutes with her using the nastiest possible tone as if I were a moron. OK - in her defense, I was completely stupid about DMO but in my defense, this is the dumbest rule in the world. Why would you go to a consultation if not to get a treatment plan? Isn't that the point of the consultation? So why then before you can have that treatment plan reviewed, would you have to go back to your regular dentist. I mean, you went to the specialist (presumably) because your dentist couldn't do what needed to be done so why do we need him to tell us again that he can't perform that treatment so that he can refer us to a specialist who can perform the treatment so they can send the treatment plan to be approved so we can go back to our dentist to confirm we are ready for treatment and should go have it done? How does this make sense? Please explain it to me. I asked to speak to someone else, a supervisor or something because this made no sense and she clearly didn't understand me. She jumped on the defensive that she did understand because she'd been dealing with DMO for 16 years and this is how DMO worked. I asked (in sort of a screech) why I couldn't just use the authorization code I already had that was for the appointment I'd been to that day on the treatment plan I was holding in my hand. She snottily said, "well now that you're screaming, I'm going to transfer you." At which point she put me on hold and I looked at Steve and said, so next time just remind me to scream so she'll transfer me. On hold for 10 minutes, she hung up on me. I was LIVID.
I told Steve I would have to call back tomorrow because I was shaking I was so angry and couldn't do it then. Steve said he'd do it. So he called on speaker phone and talked to a very polite lady but didn't ask the question quite right. He asked simply if we needed to get a referral before we could have this procedure - yes was the answer. OK was his response. What? No. I took the phone. You gotta give more info than that. I explained again the situation and that it made no sense to have to go to a dentist we'd never been to before in order to get this treatment plan authorized. She agreed that it didn't make sense but explained that some dentists don't even deal with children so we could call the dentist to see if they would just fax the referral. Then explained that also, the specialist could write a short narative explaining the medical necessity of sedating a 3 year old (which I assume would say something like "would you like to try to drill into a 3 year old's mouth who wasn't sedated?" - not sure a drill is needed but you get the idea). The specialist would fax that faxed referral, narative & treatment plan for authorization. It does take 7-10 days so our appointment in less than 10 days will be tight but she gave me her local fax number and said they'd get it done as quickly as possible. So much better, so much more informative. See how much easier it is to get answers when the person is being polite. That 2nd lady I spoke to was brusk and rude and talking over me rather than listening to my full question. She'd cut me off each time and give me the same answer repeatedly. So very unhelpful. So I thanked this lady for her help and politeness and set about calling our dentist.
It was 4:45 Thursday so I was hoping they'd still answer as they could close at 4:30 for all I know - we've never been there. I explained the full situation to "Kathy" who was very understanding and very polite. She said the lady that handles insurance is gone already but she'd talk to the dentist and then talk to the insurance lady Friday morning and she'd call me as soon as possible. She was hopeful that they would just fax a referral but wasn't sure so she'd call me. Very helpful.
She called today and said that she was very sorry but the dentist actually said faxing a referral for a patient he'd never seen was actually illegal. OK - so I can't really blame him for not risking his license to help me but come on, can I get 1 break here? Kathy went ahead and scheduled an appointment for us for as soon as we could - Tuesday - but said we should call the insurance again to see if we couldn't just use the code we already had. She said it was worth another chance. I agreed but dreaded that call and who I might get on the phone.
I called and spoke to Walt who told me just what the first lady had told me. That I could use the authorization code I had on the treatment plan to get approval. I again asked, "we went to this dentist yesterday with this authorization code and we can put that code on this plan for approval." Walt, "yes, you can." Me: "Thank you very much!" Walt is now one of my favorite people in the world - a 2 minute phone call and I'm all set. The specialist though was closed this afternoon so I'll call Monday, have them fax the info for approval and be all set again. Will probably have to change the appointment currently set for Feb 2nd but I'm ok with that as long as we don't have to go to the freaking dentist 2 more times just to get the plan approved and authorized. Poor Ethan finally gets to get his teeth fixed - he does well with the dentist but not so well with meds that taste yukky so I hope whatever they are giving him doesn't taste bad so it all goes well for him.
Insurance is a good thing - but it's so much better when it also involves polite customer service reps. So thank you Walt and the 1st & 2nd people I spoke to yesterday for all of your help.
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