INSURANCE / 3RD PARTY ISSUES WITH ORTHOPEDIC SURGERY OF THE JAW JOINT. (TMJ SURGERY)
Most all Americans are frustrated with managed care and our current health care system. This is one area that has not escaped the frustration and has its unique aspects. This blog is intended to present some realities and educate the patient of the “uniqueness” of insurance matters and this area of health care.
SOME HISTORY
In the 1980’s and 90’s, oral and maxillofacial surgeons in many states were politically active in their individual states and won, for their patients, legislation which prevented discrimination by insurers against many maxillofacial congenital abnormalities such as cleft lip and palate, corrective facial surgery for developmental facial/ jaw deformities, and orthopedic surgery of the jaw joint. Imagine a child born with cleft lip and palate being denied surgery (happened all the time) due to the fact that the surgery was “cosmetic”.
In the case of the jaw joint, it was successfully argued that if a jaw joint was severely affected by arthritic disease, injury, tumor etc, that if a health insurance policy viewed orthopedic surgery as a legitimate service for other joints of the body, they could not discriminate against surgical management of legitimately diagnosed orthopedic problems of the jaw joint because it was randomly diagnosed as “TMJ” heretofore understood to be a “dental problem”.
Today, most individuals have health insurance provided by an employer. Such insurance products do not have to abide by individual state laws previously passed. They are governed by Federal law and in particular, ERISA. Challenging ERISA would invite challenge to legal protection of unions and would create lots of problems for many Americans. Unfortunately, funding of employee health care employees is governed by ERISA and there are many loopholes. Employees are allowed to ignore individual state mandates if they wish to and area advised by insurers who administer their programs, as what to cover. So, we can sometimes be back to where we were 30 years ago. An individual can suffer from an ankylosis or fusion of another joint of the body and have no problem with having benefits for surgical replacement of the joint. Not necessarily so for the jaw since the surgical specialists trained to perform these procedures first have dental training and entire case management process of claims reviews can be denied by entry level insurance claims review/authorization processes as “dental treatment” not covered under a medical claim process. In our experience, patients sometimes have to endure the indignity of basic x-rays and examinations denied as “dental treatment”. Most insurers have established clinical policy bulletins and parameters of care protocols that even they violate or do not understand. Such are the times we live in.
Dr. William S. Kirk Jr. DDS
Tags: tmj, tmj insurance, TMJ Surgery
