Recently, a young woman in her 20’s was diagnosed with a fairly severe TMJ disc problem. Basically the discs were already degenerating and eroding away and no one knew why this had happened. I suspect it was birth trauma, but no one knows for sure. I treated her conservatively for many months, trying to get the discs to recapture into position, but it was to no avail. The new MRI clearly showed that I met her too late in the game and surgery would be the best option. When I discussed all this with the patient and her father, it was obvious they were not thrilled. Heck, who wants to hear that surgery is the only option? The father was very upset that insurance would not pay 100% of the hospital costs, nor would they pay for the surgeon’s fee. I figured I would never see them again after that visit since they were quite noticeably upset, disappointed, and distraught. They knew from day one how much damage was there, but they expected me to work a miracle and fix everything non surgically. My consent forms are quite clear- surgery all depends on if I meet the patient soon enough before the damage becomes extreme. In this case, it was a pretty bad situation.
So I wished them well that day, thinking they would find some other doctor who would tell them what they wanted to hear: You do not need surgery. Well, as it turns out, the father diligently went to his insurance company and got the names of 20 TMD specialists who could do the surgery, and it would be covered at 100%! Yippee! And being the very diligent father, he took his little girl to ALL of these so-called participating providers who knew what they were doing. Well folks, as it turned out, 10 of the doctors on the ‘list’ had never heard of TMJ surgery (yet according to the insurance company they did). Another 8 had no idea how to do the procedure (even though they were on the provider list as well). And the other 2 had perhaps done a couple of these procedures. The father already knew that my surgeon, Dr. Gregory, had done thousands of joint surgeries over the years with a success rate of around 94%. Needless to say he was appalled that there was so little understanding about what needed to be done.
A few weeks later I was shocked to see the young woman on my schedule. She and her father had come back to discuss having the surgery with Dr. Gregory. The father basically told me he was disgusted with what the insurance company tried to do- they tried to save money by having an inexperienced surgeon do surgery on his daughter. To me, this borders on criminal intent. The insurance carrier wanted someone to do this surgery when he/she had no right to do this. Did they figure that it might work out anyway? I was shocked when the father told me how he went to all those doctors only to learn that taking the short cut might damage his daughter’s future.
Ultimately, our young woman had Dr. Gregory do the surgery and her pain was literally gone that same day. I have seen her for multiple follow ups since then, I took out her sutures, and she said she feels much better now. Although I am very much against surgery for my patients, I must admit that 1 or 2 out of the 100 patients per week really do need it. This week alone I met several new patients that were fairly warned that surgery might be needed, but I will do all that I can to avoid it and manage their cases non surgically. I am always sorry to report that the insurance company is not really there to help you get better. They exist solely to make profit for their shareholders and are simply a for-profit entity. There is no ethics involved when talking about insurance companies so I do not understand why patients look to their insurance for ‘proper’ care and consideration. The father and daughter learned a lesson from all of this, but so did I! Now when discussing surgery, I explain that you are very welcome to go get other opinions- I wholeheartedly recommend it! However, please be aware that due to the lack of knowledge in this area, you will most likely find doctors who will not recommend the surgery and that is the way it is.