Consumers have a responsibility to know their insurance benefits before they have a medical or dental procedure.
Your provider also has a responsibility: to bill your insurance in an accurate and timely manner.
Here’s a case that took more than six months to resolve, but never should have happened. One simple insurance billing omission took twists and turns, and ultimately, ended up just fine for the patient.
But had he not asked questions, he would have been stuck with a $9,000 bill.
Last summer, Ronald Martins of Linden went to the hospital for knee surgery.
He left missing a permanent dental bridge for his three front teeth, and no one wanted to pay for it.
It started in January 2016, when Martins, 60, had a total replacement of his right knee.
There were no dental complications, Martins said.
But by August, there were complications with his knee, and he returned to the hospital for surgery on Aug. 19.
“My permanent three-tooth bridge was intact before the surgery, but was missing after the surgery,” Martins said. “The anesthesiologist did not take notice of this.”
But Martins noticed when he woke up after surgery.
He said he alerted hospital employees.
“A search was made of the operating and recovery rooms, but nothing was found,” Martins said. “X-rays confirmed that the bridge was traveling through my digestive system.”
Martins said he doesn’t know exactly what went wrong during the surgery because he was under anesthesia, but said he was intubated and had a tube in his mouth during the procedure.
Prior to the surgery, Martins said, he told the anesthesiologist that he had no removable dental work, but had two permanent bridges.
He tried to get answers.
“The anesthesiologist told me that I might have bit down on the device in my mouth while I was unconscious, forcing the bridge to come loose,” Martins said.
Martins also spoke about the bridge to the hospital’s patient relations rep, but so far, no one claimed responsibility for the incident.
He remained in the hospital for a second complete knee replacement on Aug. 24.
The bridge took a six-day journey through Martins’ digestive system while he was still in the hospital, and it was passed without complications.
Before his discharge on Aug. 27, Martins said, he again spoke to the hospital’s patient relations rep, but no decisions were made about who would pay to replace the bridge.
He went to his dentist on Aug. 29.
“My dentist examined the old bridge and determined it broke off during anesthesia. It was no longer usable as a permanent bridge, only as a temporary,” Martins said. “It was not a clean break, and he had to also do a root canal in the same area to make it stable enough for the new bridge.”
The bridge was sterilized, Martins said, and installed back in his mouth as a temporary.
The new permanent one was installed on Sept. 15.
Because the original bridge was only two years old, the dentist’s office said not to expect Martins’ insurance to pay for the repair.
The bill? $9,080.
On the same day the permanent bridge was installed, Martins said, he called the anesthesiology practice. It promised to review the case, he said.
Then on Sept. 29 Martins got a call from the dentist’s office. It said it spoke to the anesthesiology practice, which said it would not pay for the repair.
Next, Martins received a letter from the hospital on Oct. 3. It said after a review, “it was determined that there was no deviation in the standard of care, therefore [the anesthesiology practice] respectfully declined to reimburse you for any dental repairs.”
Martins wasn’t ready to give up yet.
“My position is simple: I went to sleep with all my teeth intact, and woke up missing three,” he said. “I had the same operation in January of this year, and did not have any dental issues.”
He asked Bamboozled for help.
We reviewed Martins’ paperwork and the X-ray of the bridge in his digestive system.
The anesthesia consent form signed by Martins listed many warnings. It said, “Insertion or removal of airways may cause damage to the teeth, dental prostheses, lips, sore throat or hoarseness.”
Then it had a fill-in-the-blank, left empty, saying, “For your particular procedure the anesthesia risks ALSO may include…”
Does that mean the anesthesia practice and the hospital should be off the hook for damage?
We couldn’t help but imagine, given that Martins’ bridge was obviously swallowed: What if he choked on it during the procedure? If it went in his airway instead of his esophagus? Why wasn’t anything blocking the tube, or, at least catching anything large that might try to make its way down there?
We reached out to the hospital and to the anesthesia practice.
While we waited for answers, we reached out to several anesthesiology trade groups and associations to learn about best practices in cases like this, but none responded to our requests.
So we dove into some scholarly medical journals to see what we could learn.
An article in “Anaesthesia and Intensive Care” in 2000 said “Damage to teeth is the most common complaint among anesthetists.”
A similar sentiment is found in most of the articles and research.
A 2014 report in Oral Health and Dental Management said it may be necessary for a dentist to advise an anesthesiologist, or an anesthesiologist should receive “formal training regarding oral and dental anatomy,” to minimize the risk of dental injury.
It, too, said dental damage “is one of the most common anesthesia-related adverse events and is responsible for the greatest number of malpractice claims against anesthesiologists.”
But how common is the problem?
The report noted several older statistics.
It cited a 2006 article that found injuries in 1 in 20 patients, or 5 percent of those who undergo general anesthesia.
Other studies mentioned — mostly from the late 1990 or early 2000s — put the rate between 0.04 and 12.08 percent of patients.
Several of the studies discussed how to avoid the injuries. Conversations between patients and anesthesiologists were commonly recommended, as was the idea that a patient should first visit a dentist to assess the risk of losing teeth, implants or other dental devices.
The 2014 article suggested anesthesiologists should examine a patient’s teeth before and after intubation.
Several others recommended the use of mouth guards during intubation.
Martins said he doesn’t know if a mouth guard was used during his procedure.
Our queries started a series of calls between Martins, the anesthesia practice and the hospital.
Martins was told the case would be examined, but a response would take several weeks.
The anesthesia practice’s “risk management” department “indicated that [the practice] might be willing to pay something towards the dental bill, but not the whole thing,” Martins said.
In another call, the rep asked Martins to confirm with his dentist that Martins’ insurance plan won’t pay anything toward the bill.
So Martins went back to the dentist, and guess what?
The dental practice never actually billed the insurance company.
The dentist’s billing rep figured Martins’ dental insurance wouldn’t pay because the bridge was too new to be covered for a replacement, Martins said he was told.
They figured wrong.
When the dentist finally submitted a claim, everything changed. Between his dental and medical insurance, the entire payment required under the insurance contract was covered except for a $30 co-pay. Martins said he plans to ask the anesthesiology practice to pay that.
Had the dentist’s office billed insurance from the start rather than assume the costs would not be covered, all this confusion never would have happened. And had insurance never been billed, Martins would have been on the hook for the larger $9,080 bill.
And he now realizes the importance of making sure a health care provider actually bills the insurance company, a takeaway we hope you remember.
Martins had another lesson for you, dear readers.
“My advice to anyone going under the knife would be to make sure that the anesthesiologist is aware of any dental bridgework, and should ensure that said bridgework is in the same location after surgery, not in the patient’s digestive tract,” Martins said.
Have you been Bamboozled? Reach Karin Price Mueller at Bamboozled@NJAdvanceMedia.com. Follow her on Twitter @KPMueller. Find Bamboozled on Facebook. Mueller is also the founder of NJMoneyHelp.com. Stay informed and sign up for NJMoneyHelp.com’s weekly e-newsletter.