More than two months?! - TMJ Disorder -TemporoMandibular Joint Message Board

Lori Lynn · 06-11-2003, 11:32 AM

I'm so annoyed right now.

I had an appointment with my OS scheduled for July 3rd, and had to postpone it. The next nearest date they can see me is SEPTEMBER 4!

I think it's time to (1)write a nasty letter to my insurance company, and (2) find a new doctor. I've been trying to get treated by this guy since late January, didn't have my first appointment until March, and have only seen him twice. My splint was made by another dentist for this guy, but was never adjusted in the month and a half I've had it. The best part is seeing all the commercials saying how wonderful this insurance company's coverage is, how they do more for their patients than anyone else. Ha.

Anyone have any luck getting an insurance company to cover out of network doctors? This guy seems to be their only TMJ guy, and not only is he way overbooked, but it's two hours away from my home.

shell389 · 06-11-2003, 11:46 AM

Lori, It is really hard to get insurance to pay out of network. Usually has to be a very extenuating circumstance. If you told them about the unavailability of appts. I guess it's possible they would make an exception but not too likely. You could always try though.

I live in PA too and have a dentist I am treating with that specializes in TMJD and maxo. and oral facial pain. I noticed it says you are near the Poconos. I am about 2 hours from there and the dentist I see would be even closer. But he is probably not in your insurance network. I don't think he participates with any insurances.

Hope you can get an appt. sooner than September. Let me know if you want the name of my dentist. His is listed on the American Academy for Craniofacial Pain.

Shell

TiffanyAnn · 06-11-2003, 12:36 PM

Hi:
I just had a thought...perhaps if the diagnosis code was given as MPD instead of TMJ maybe your insurance company might be more inclined to pay for your treatment. No assurances of course but worth a try maybe.
Tiffany

Lori Lynn · 06-11-2003, 12:49 PM

Thanks Shell & Tiffany!

There are some promising looking docs on the AACP site. Allentown isn't any further than where I'm going now, and would probably take less time with the turnpike.

My insurance does cover TMJ treatment. They covered half my splint, which was nice. But it has to be from one of their doctors, and they seem to only have ONE, who is obviously very overbooked. I'll give complaining a try... it can't hurt.

The worst that will happen is I'll have to pay out of pocket. If I don't try, I'll have to do that anyway. I have some friends who worked for insurance companies giving me some pointers. I'll let y'all know how it turns out.

CherylLynn24 · 06-11-2003, 08:51 PM

Lori,

WOW!!! September is a loooong time to wait. From what I understand, a splint needs to be adjusted at least once a month, if not more. If that's the best that his office can do, (September) I think that I'd start looking around for someone new.

Most of the specialists/dentists that my Son sees are out of network, but our insurance pays 70% of those compared to the in network. The claims are always sent in as Myofacial Pain Dysfunction, (as Tiffany said) and a larger amount is paid out than if it were sent in under TMJ. MPD is considered a medical condition, that's probably why. Let us know what you chose to do, and Good Luck,
Cheryl