faith7777
04-07-2008, 01:14 PM
thelma we have pretty good insurance yet it seem that insurance does not cover anything to do with tmd....so far we have spent alot of money out of our own pocket........... my first visit with dr steven syrop i had to pay $500.00 out of my own pocket and each additional visit $250.00 i've been seeing syrop fo about a year ........am thinking about going to see michael gelb for a second opinion and his visit is $575.00. how do i get my insurance to help me pay for something ?
have you ever seen michael gelb in manhattan and what did you think??????
with braces and splint am looking at 10,000.00 already spent so much on this...............HOW DO I GET MY INSURANCE TO HELP PAY AFTER ALL THIS TMD IS A MEDICAL PROBLEM.
have you ever seen dr steven syrop and what did you think about him???????
thanks .
have you ever seen michael gelb in manhattan and what did you think??????
with braces and splint am looking at 10,000.00 already spent so much on this...............HOW DO I GET MY INSURANCE TO HELP PAY AFTER ALL THIS TMD IS A MEDICAL PROBLEM.
have you ever seen dr steven syrop and what did you think about him???????
thanks .
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Thelma-Louise
04-07-2008, 10:37 PM
I never went to Dr Syrop - I think another member went to him too - but I did put his name on my list of possible drs to see. How did you make out with him - you mention its been almost a year - was he able to help at all?
I did see Michael Gelb - the dr that was treating me at the time, Dr McClendon, sent me to him for an evaluation. At one point I got locked closed and Dr M sent me there for him to unlock my jaw. He did trigger point injections but I think my jaw unlocked on its own a couple days later. I did go back to him 2 more times to be fitted for a full mouth guard which I basically could not wear. As soon as I put it in I thought I was going to choke or gag and it made me feel like I could not breath - maybe b/c I tend to breath through my mouth? He had his staff adjust it a few times but I felt I was paying to see him and not his staff so I never returned. I am not sure why - maybe b/c another dr was treating me at the time so he didn't want to interfere with another drs patient - but he really did not offer me much in terms of any recommendations or treatment options. I have heard equal amts of pros and cons about him - both from other professionals and members here. I know for some he helped quite a deal and for others he could not - but it could be b/c each case is so different.
But one really good thing with Dr Gelb's office is that they took care of all the medical and dental insurance claims - calling the ins co's to find out my coverage - which one would pay for what - and submitting the claims for me - but I had to pay them up front, which is how I first found out that my medical insurance co coverered me for myofacial pain syndrome, craniofacial disorders and tmj pain and most therapies and splints to treat it. My dental insurance basically became useless - they would not cover anything except a cleaning and a few xrays.
I am pretty sure though due to my deductible and copay I still had most of Dr G's fee to pay out of pocket - but they covered his trigger point injections and mouth guard in full. They later covered other splints I tried as well - one was $3K and they paid it in full - the dr I was then seeing had his office look at the claims Dr Gelb's office had submitted and submitted claims on my behalf as well - but again they insisted I pay up front first and wait for reimbursement from the ins co.
Unfortunately,although tmj is only recently starting to be considered to be medical - its on a state by state basis - not national - in terms of private insurance cos. NYS still does not fully recognize all tmj treatment as medical so most private insurance cos doing business in NY stop short of any dental treatments involving crowns, bridges or orthodontia, bite adjustments, etc - even if they are required to treat the tmj pain and symptoms.
With regards to the treatment you are considering, most private dental insurances offer a one time (lifetime max) of orthordontia treatment usually capped at a certain amt depending on the plan you are in. Based on what drs charge these days they seldom cover the full amt. The splint may be covered under medical ins but it may have to be submitted under Myofacial Pain Syndrome or Craniofacial Pain Disorder if your plan does not cover TMJ/TMD specifically.
Another thing with dental and medical insruance is that the amt they will cover is not only based on "usual and customary" charges for an area or locale - but whether the dr is "in-network" or "out-of-network" meaning they have agreed to accept certain fee and treatment rates or not. With more and more drs these days not participating in private insurance networks and therfore requesting payment in full up front, members are more likely to pay more, since non-network providers (drs) can charge whatever they want or the market will bear and insurance cos will then reimburse the member based on the fees and rates established and allowed by the insurance co for those services.
I hope that helps some and that I haven't made it sound too confusing or obnoxious. Sometimes the insurance issues are just as complex as finding the right dr and successfully resolving the tmj!!
I did see Michael Gelb - the dr that was treating me at the time, Dr McClendon, sent me to him for an evaluation. At one point I got locked closed and Dr M sent me there for him to unlock my jaw. He did trigger point injections but I think my jaw unlocked on its own a couple days later. I did go back to him 2 more times to be fitted for a full mouth guard which I basically could not wear. As soon as I put it in I thought I was going to choke or gag and it made me feel like I could not breath - maybe b/c I tend to breath through my mouth? He had his staff adjust it a few times but I felt I was paying to see him and not his staff so I never returned. I am not sure why - maybe b/c another dr was treating me at the time so he didn't want to interfere with another drs patient - but he really did not offer me much in terms of any recommendations or treatment options. I have heard equal amts of pros and cons about him - both from other professionals and members here. I know for some he helped quite a deal and for others he could not - but it could be b/c each case is so different.
But one really good thing with Dr Gelb's office is that they took care of all the medical and dental insurance claims - calling the ins co's to find out my coverage - which one would pay for what - and submitting the claims for me - but I had to pay them up front, which is how I first found out that my medical insurance co coverered me for myofacial pain syndrome, craniofacial disorders and tmj pain and most therapies and splints to treat it. My dental insurance basically became useless - they would not cover anything except a cleaning and a few xrays.
I am pretty sure though due to my deductible and copay I still had most of Dr G's fee to pay out of pocket - but they covered his trigger point injections and mouth guard in full. They later covered other splints I tried as well - one was $3K and they paid it in full - the dr I was then seeing had his office look at the claims Dr Gelb's office had submitted and submitted claims on my behalf as well - but again they insisted I pay up front first and wait for reimbursement from the ins co.
Unfortunately,although tmj is only recently starting to be considered to be medical - its on a state by state basis - not national - in terms of private insurance cos. NYS still does not fully recognize all tmj treatment as medical so most private insurance cos doing business in NY stop short of any dental treatments involving crowns, bridges or orthodontia, bite adjustments, etc - even if they are required to treat the tmj pain and symptoms.
With regards to the treatment you are considering, most private dental insurances offer a one time (lifetime max) of orthordontia treatment usually capped at a certain amt depending on the plan you are in. Based on what drs charge these days they seldom cover the full amt. The splint may be covered under medical ins but it may have to be submitted under Myofacial Pain Syndrome or Craniofacial Pain Disorder if your plan does not cover TMJ/TMD specifically.
Another thing with dental and medical insruance is that the amt they will cover is not only based on "usual and customary" charges for an area or locale - but whether the dr is "in-network" or "out-of-network" meaning they have agreed to accept certain fee and treatment rates or not. With more and more drs these days not participating in private insurance networks and therfore requesting payment in full up front, members are more likely to pay more, since non-network providers (drs) can charge whatever they want or the market will bear and insurance cos will then reimburse the member based on the fees and rates established and allowed by the insurance co for those services.
I hope that helps some and that I haven't made it sound too confusing or obnoxious. Sometimes the insurance issues are just as complex as finding the right dr and successfully resolving the tmj!!