Solve it 7: Braces

(WHDH) — Smiling hasn’t always been fun for Briana Paredes.

“I’ve always wanted braces growing up because I’ve always had crooked teeth,” she says.

So after enrolling in Mass Health, she decided to take advantage of the insurance’s braces coverage.

“Everybody likes a nice smile, right?” asked Briana.

According to her policy, Mass Health would cover the cost, as long as she began treatment before her 21st birthday, which was getting close.

“I went to the orthodontist and see if they could contact Mass Health, they did and Mass Health approved for the braces,” says Briana.

The process took longer than Briana expected, and she didn’t receive the approval letter until a month after her 21st birthday, but it clearly shows that Mass Health would cover her treatment.

“I was ecstatic about getting them on. I called right away and told them I got approved for braces and that I would like to come in and get them on my teeth,” she says. “Great come on in, they said.”

Briana’s orthodontist put the braces on her top teeth, and scheduled a follow up visit to put them on her bottom teeth.

“So I made another appointment and I went back and they said Mass Health denied the bill,” she says.

Briana was shocked! Despite the pre-approval letter and the braces already on her top teeth, she says Mass Health now refused to pay for her treatment and that she would now be responsible for the bill.

“I was like, I can’t afford that. I’m a 21-year-old girl, I take care of myself”, she says. “It’s a struggle too and the last thing I could afford is fifty-four hundred dollars to get braces put on my teeth,” she explained.

Determined to keep her treatment on track, Briana reached out to Mass Health, to appeal the decision, but says the representative told her she didn’t qualify for braces because she was already 21 years old, and that they didn’t verify her age when they issued the pre-approval letter.

“You’re the patient here. Do you think the orthodontist and the insurance company should have known how to handle this,” Kris asked.

“Absolutely,” Briana replied. “I’ve just waited so long to get them on my teeth,” she says. “I was excited and they just crushed my dreams telling me they couldn’t pay for it and telling me to pay so much money to do it.”

Briana needed help so she called Solve it 7 and we went to our legal expert.

“Bob, who’s responsible here,” Kris asked.

“Mass Health would be ultimately responsible, they approved it,” Bob Harnais of the New England Bar answered. “They made a commitment. They should pay it. The procedure started before she was 21. I don’t think they have a choice both on legal and moral grounds,” he says.

We contacted mass health to try and straighten out this braces blunder. The representative told us that their third party dental provider authorized Briana’s treatment in error.

“Mass Health is aware that our third party dental provider approved the prior authorization request in error. They have addressed their internal technical systems issue.”

But that Mass Health wants to be fair and reasonable and will pay for her braces.

“As a general matter, Mass Health seeks to resolve such errors in manner that is fair and reasonable to any impacted members (and in this case our third party dental provider will pay for the braces).”

“And, they’ve addressed the issue,” Kris said.

“I was ecstatic; jumping excited,” Briana said. “You guys are awesome. Thank you for helping me,” she says. “You guys did a great job!”

And we’re happy to report that Briana already has the braces on her bottom teeth, so her treatment is back on track.

Need us to fight tooth and nail for you? Head to your phone and give us a call at 617-367-7777 or send us an email to SOLVEIT7@WHDH.COM.

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