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Vync

Reimbursement Of Billing For Sc Conditions

Question

Here are my recent antics with the VA Business Office, which are based on information I learned here on Hadit.

Billing my insurance for SC treatment

The VA has been billing my private insurance for my SC treatment and prescriptions. After visiting the VAMC Business Office, my records are now being reviewed for reimbursement to my private insurance.

Retroactive reimbursement of VA billing me for SC conditions

In 2000, the VA sent me a bill for treatment, which I paid. Later in 2000, my 40% SC was approved with an effective date of 1995. After visiting the VAMC Business Office, my records are now being reviewed for reimbursement for reimbursement to me.

External treatment reimbursement due to refusal of treatment by the VA

Several years ago, the VA dentist refused to treat my problem. I had swelling around a tooth, which also extended into my sinuses. I sought private treatment, which identified infection in the root. A simple root canal procedure was done and I had no problems since. Of course, the visit was expensive and my private insurance only covered part of it, so I had to pay the rest. After visiting the VAMC Business Office, I was told that I might be able to be reimbursed. I was asked to gather the private treatment and billing records and submit them through the patient representative. There is no guarantee, but the premise is that the care I received at the VA was substandard. This is more interesting because the dentist who refused to provide treatment is now in charge of the VAMC dental clinic.

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External treatment reimbursement due to refusal of treatment by the VA

Several years ago, the VA dentist refused to treat my problem. I had swelling around a tooth, which also extended into my sinuses. I sought private treatment, which identified infection in the root. A simple root canal procedure was done and I had no problems since. Of course, the visit was expensive and my private insurance only covered part of it, so I had to pay the rest. After visiting the VAMC Business Office, I was told that I might be able to be reimbursed. I was asked to gather the private treatment and billing records and submit them through the patient representative. There is no guarantee, but the premise is that the care I received at the VA was substandard. This is more interesting because the dentist who refused to provide treatment is now in charge of the VAMC dental clinic.

Vync,

Under what contention do you feel the VA dentisit was in error or provided

substandard care, in refusing to treat your dental problem ?

I feel these would be the questions the decision maker would have.

1) Was the claimant within 90 days of separation ?

2) At the time, was the tooth in question covered by being SC'd

for treatment purposes ?

3) Had any doctor provided a referral to dental requesting treatment

for this tooth and stated it was exacerbating other medical condition ?

jmho,

carlie

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Ad


Regarding dental eligibility, I am SC for TMJ, so...

§4.150 Schedule of ratings—dental and oral conditions.

9905 Temporomandibular articulation, limited motion of:

Inter-incisal range:

0 to 10 mm 40

11 to 20 mm 30

21 to 30 mm 20

31 to 40 mm 10

And...

http://www4.va.gov/healtheligibility/coveredservices/SpecialBenefits.asp#Dental

If you:

Have a service-connected compensable dental disability or condition

You are eligible for:

Any needed dental care

The VA dentist indicated I complained about tooth pain, but noted everything was normal. Later the same day, the private endodontist noted visual swelling around the tooth, outer jaw, and even into my sinuses.

This is pretty obvious, but one thing I learned is that despite how obvious, nothing is ever the way that it seems with the VA. I am considering taking copies of the VA records to my endodontist and asking him to write a statement indicating that he provided care which should have been provided to me by the VA. The doc was really cool and prides himself on patient satisfaction.

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So the question to #2 would be yes.

carlie

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When I was waiting for IU I had extensive dental treatments. When I got my IU I asked to be reimbursed for the dental treatment I got while my IU was on appeal. I was paid the VA rate for this care after much hemming and hawing. A lot of things can be done if you are determined.

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Vync,

The more I look into this and study it,

something that keeps knawing at me is this question.

Is the SC'd TMJ a dental condition or actually

an oral condition that relates to the tm joint.

Has VBA ever put in writing that you are to recieve

any and all dental treatment ?

As everything VBA - even this can be confusing.

carlie

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