What Happened

Not long ago, I had a pretty decent smile. Then on November 23, 2010 I had a bike accident. My wheel slipped through two metal grates on the Lasalle Street Bridge in downtown Chicago. The bike stopped moving in a split second but my face kept flying forward and met the bridge hard. It must have looked a little something like this. It hurt. It hurt a lot. I managed to stumble off of the roadway. There was blood everywhere. Someone called an ambulance and I took a ride to Northwestern Hospital. Moving my tongue through my mouth, it was clear that things weren’t right. In fact, the contents of my mouth had moved around quite a bit. X rays were taken. I had some deep facial lacerations(graphic), three teeth and some jaw knocked out (graphic), and six more teeth jarred loose. Dental residents splinted my loose teeth with wire, my face was sewn up–rather excellently, I might add–and I was sent home. Quite a day.

Where Things Get Confusing

Time passed. I visited the dentists at Northwestern who splinted my teeth, but things weren’t healing up the way they had hoped and after giving the splinted teeth a couple of months to set it was time to start thinking about how to repair the damage. The folks at Northwestern referred me to one of their oral surgeons. He sounded pretty good, but after checking with my primary care provider, I discovered that he wasn’t in my network. Now I figured that this meant that he wasn’t in my Humana HMO network. I had signed up with Humana through my work. However, it turns out that she was referring to my IPA network. When I selected my primary care physicians, I had unwittingly opted into a sort of sub-network called Resurrection Preferred that contracts with Humana to provide all of my care. So in order to see an oral surgeon, I had to start with one of their providers. As it turns out, Resurrection Preferred has only two oral surgeons to select from. So after some back and forth with my primary care doctor, I made an appoint to meet with him. This was the end of January. The oral surgeon entered the exam room with his scrubs on and wearing one of those head-mounted lights like a spelunker. He looked at my mouth, the X rays I had brought with me, then asked, in so many words, what I was doing there. What I needed, he said, was a good restorative dentist to “quarterback” my care. Because of the extensive and complicated nature of my injury, I would likely have “one good shot” at achieving a good result. He recommended a particular dentist who could coordinate all aspects of my care including root canals, bone grafting, and tooth implantation.

So okay. There are no restorative dentists in my IPA network, let alone this particular one. After weeks of lobbying Resurrection Preferred and getting testimony from their oral surgeon, I finally got permission to visit the suggested dentist, thank goodness. I meet with him. He seems fantastic. He comes up with a plan to help put my mouth back together and submits it to the IPA. Negotiations ensue. The IPA offers to pay for a small fraction of his estimate. More back and forth. Then negotiations stop. Humana, the big insurer, steps in. I have heard from Resurrection Preferred that taking over dental claims was Humana’s idea. I have heard just the opposite from representatives at Humana–that Resurrection punted to them after my claim became too costly. Whatever the case, my request for care was suddenly in Humana’s realm and they decided to take a wholly different tact. They denied the dentist’s treatment plan because he was “out of network.”

Out of Network??

To review: when I left the dental team at Northwestern, I went out of my way to way to see an oral surgeon who was in Resurrection’s network. He referred me to a restorative dentist. There are no similar practitioners within the Resurrection network so after much finagling, I am able to see this person that the Resurrection provider recommends. But when Humana takes over, suddenly the network changes. So the expectations about who I am supposed to be consulting with changes. Never mind that months and months have passed and a definite plan has been arrived at. Casts of my teeth have been taken. An endodontist has been consulted who has done testing to see which teeth need root canals; I can no longer be seen by her either. Now that Humana rather than Resurrection is overseeing things, I am expected to change everything midstream. This was May 13.

So fine. I figure I am stuck. If Humana is only going to consider reimbursing someone who is in their network and they actually have providers capable of handling my case, so be it. I will meet with someone on their list. That the dentist who had been working with me up to this point decided to bail, explaining that he had already expended too much time and energy on my case, with little promise of proceeding: this also influenced my thinking. I reach out to the same Humana representative who had told me that my dentist was out of network and ask for a list of in-network providers. She faxes me a list of oral surgeons. After some research on my part, I discover that indeed a few of them do specialize in restorative work. I select one from my alma mater, UIC, who seems to have a good reputation and call to set up an initial consultation. I actually end up speaking with him over the phone, and when he hears I have Humana, he advises me to make absolutely sure that he is considered in network; there have been issues before. So I call Humana back, and again speak with the woman who faxed me the list. She confirms that this doctor is indeed in their network. However, she explains that in cases such as mine, where Humana has taken over from the IPA, typically they will only cover “facility fees.” They will not be covering “professional fees.” But, I ask her, won’t the vast majority of my expenses be professional fees: whatever the dentist charges for the root canals and implants, for instance. Silence on the other end of the line. What should I do if I want to get the professional fees covered? She said that I should speak with Resurrection Preferred, the IPA. At this point, I’m pretty sure I asked her if she was kidding. I may have cried a little bit, too.

Inside Voice

When the dentist I had been working with decided to drop me–and I entirely understand this decision; his staff had put in many hours in phone conversations and emails with Resurrection Preferred with little to show for it–I asked for all of their correspondence with the IPA. A large portion of the dealings were with one person. In her emails, she comes across as both helpful and exasperated with the bureaucracy of her organization. I decide to try to phone her directly rather than just speaking with whatever claims expert is in the office as I had been. She is out of the office and I am directed to her voice-mail. Later that afternoon I get a call back from her. Amazingly, she is on vacation on the west coast but felt that because the way things have turned out and all of the time that had passed that she should respond quickly. She agreed that the current situation is unreasonable and that my best course of action was to lodge a formal appeal of Humana’s denial of coverage. When I mentioned that I was frustrated and considering hiring a lawyer, she intimated that this probably wouldn’t go very well. She strongly suggested that I enlist the help of my human resources representative and try to keep working within the system. Perhaps a bit naively, this is what I have decided to do. In typical cryptic fashion, Humana has sent me a letter stating: “we are currently doing research and and will send a decision letter within the required timeframe” without actually stating what the required timeframe is.

The Mouth

In the meantime, my teeth structurally are just as they were immediately after the accident occurred. Plaque has formed around the wire splint and I have a lot of gingivitis as a result. Most of the remaining front teeth have “died” as a result of the trauma and may or may not be salvageable with root canals. I can’t bite down on anything. The fractured tooth still has an exposed nerve making brushing difficult. I speak with a bit of a lisp and look like an old school hockey player. Though none of this constitutes the end of the world, it is awfully inconvenient. And because the issue is right out in front of me at all times, I get a lot of questions and a lot of comments. I smile less, and I wonder what people are thinking of me as I speak.

Moving Forward

So rather than simply waiting for Humana to make their decision, I thought I would write about what has been going on and to get some input from you out there. Have you been through anything similar? What would you suggest I do? I plan to research the relationships between “major medical” insurers like Humana and the small IPAs that they contract with. How do they typically reach decisions about who covers what? I am also  interested in issues of physical appearance. Have you suffered an injury that left you disfigured, if even in a small way? How did it affect you? What did you learn from it? Finally, I will be exploring my love of urban cycling and my continued obsession despite the sting. For those of you wondering why I do not have a lawsuit pending against the city given that roadway conditions led to my accident, read here and here. I was not in a bike lane meaning that, according to a ludicrous legal precedent, I was a permitted but not intended user of the road.

I would appreciate any and all feedback and will be writing more soon. Thanks!