Our Wins
Blue Shield of CA HMO - Client AN
This patient had a very restrictive HMO plan with Blue Shield of California, and her medical group did not offer an orthognathic surgeon. Through the course of 5 lengthy phone calls and 1 written appeal, we were able to overturn the denial for her MMA surgery with Dr. David Bell in Irvine, CA.
Anthem BCBS Virgina PPO - Client DS
This individual was on a self-funded plan administered by Anthem BCBS Virginia. After multiple appeals, we were able to secure a network gap exception for his double jaw surgery with Dr. David Bell in Orange County, CA.
Anthem Blue Cross CA PPO - Client AT
This patient was seeking both an out-of-network gap exception and a single case agreement (SCA), also known as a "letter of agreement" (LOA) for double jaw surgery with Dr. Robert Relle at LACOMS. We were able to reduce his out of pocket expense from $56,000 to $10,000 — saving him $46,100 on his maxillomandibular advancement surgery!
Aetna PPO - Client KH
With this patient, we were seeking in-network level benefits for an out-of-network jaw surgeon. The patient is undergoing double jaw surgery and did not require prior authorization for orthognathic surgery. He would have been reimbursed at the out-of-network level which only amounts to about 3% of the cost of surgery. We filed a lengthy request for reconsideration with the insurer, requesting that they provide the patient with a network gap exception, and we were successful.
Prior Authorization (Precert) showing this below.
United Healthcare PPO - Client KH
This patient underwent MSDO (mandibular distraction osteogenesis) in December 2023. While he was successful in obtaining Prior Authorization for the procedure, he was not successful in getting it approved at in-network rates (known as a gap exception). We reviewed his case and identified a procedural issue with the way his insurance handled their denial letter (it was to do with timing and an invalid claim that they made). We escalated the case to the CA DMHC (Department of Managed Healthcare) and were able to overturn the denial due to this oversight by the carrier. The patient was reimbursed every last penny he paid out of pocket. See claim EOB below.
