Crazy for Crowns

This is what I do at work, when I'm not searching the South Dakota Craigslist for unused Staub chicken pots. Or, I should say, this is what they force me to do. Just think of all the poor and helpless, social worker-less dying people left to suffer while I fight for my right to dental work. Shame on you, union.

The good news is that it prevents me from delving into the more shallow recesses of my brain which, with just over seven weeks to go, are percolating with a million and three Things Still Left Undone Before the Wedding. Trust me, one peek would turn your hair white.

And now, your dinner (imagine the important parts in bold print):



May 4, 2006


Mr. X
Supervisor, Dental Department
xxxxx National Benefit Fund
xxx West 42nd Street, 4th floor
New York, NY xxxxx


Mr. xxxxx:

This letter is to detail in writing the efforts I have made thus far in obtaining authorization for a porcelain crown, following a partial break of my rearmost right bottom molar on April 4th, 2006.

· April 4th, 2006: I received a dental exam and a full set of dental x-rays from an associate of Dr. Samuel X(212-757-xxxx), whose office number I found on the 1199 dental provider online directory. Dr. X's associate examined my broken tooth and advised me of my urgent need for a crown, but then told me that they would not accept full payment from xxxxx, and that I would be responsible for at least $1200 of the fee.

· April 5th, 2006: I received a list of Members Choice xxxxx dental providers from your office, all of whom were either no longer participating with xxxxx, no longer present at the listed address/phone number, or otherwise unavailable.

· April 5th, 2006: Due to my inability to locate an available participating provider, I visited the dental clinic at xxxx Medical Center, where I was once again advised of an urgent need for a crown, but was again told I would be responsible for a sizeable fee.

· April 6th, 2006: I received a dental examination from an associate of Dr. Jay X (718-652-xxxx), to whom I was referred by another xxxx member. Dr. X's associate examined my tooth and once again advised me of my urgent need for a crown.

· April 7th, 2006: I hand-delivered a pre-authorization request for a porcelain crown from Dr. X's office to a woman in your xxxx dental department. When she advised me that the approval might take up to 8 weeks, I told her that I was in serious pain and that three dentists had advised me to have a crown placed within the next week or two. At this point, your associate told me that the authorization should be reviewed within a week or two.

· Week of April 17th, 2006: I called your office to check on my authorization and spoke to several people, including yourself. At that time, your office advised me that my authorization had been denied due to insufficient x-ray evidence of a need for a crown. It is unclear when your office would have alerted me of this denial, had I not contacted you myself. At that time, you personally advised me that you would resubmit the request for authorization. You did not advise me to have another set of x-rays taken at that time. I reminded you and your associates that I was in pain and that I was fearful of developing an infection and/or losing more of my tooth.

· April 25th, 2006: I again called your office and spoke to a female associate, who advised me that my authorization had not yet been re-reviewed, and that it might be another “few days” before it was reviewed. I once again reminded your associate that I was in pain and fearful of an infection or further tooth damage.

· May 1st, 2006: I again called your office and spoke to your associate Mr. X, who advised me that the authorization had still not been re-reviewed. After placing me on hold and speaking with you, Mr. X told me that, according to you, you had advised me on the week of the 17th that I should have another x-ray taken of my tooth, and that this should be submitted with my renewed request for authorization. I advised Mr. X that no such guidance had been provided, but that you had instead told me that the request would be resubmitted as-is.

· I spoke to you personally later in the day on May 1st, at which point you also suggested that you had advised me on the week of the 17th to have another x-ray taken. As I told you then, I am certain that you offered no such instruction. Obviously, as my consistent contact with your office would indicate, I am eager to resolve this issue, and would have gladly and swiftly walked to Dr. X's office at that time to have another x-ray taken. You advised me that once I had received the new x-ray, I could hand-deliver it to your office and that you would expedite the review. You also told me I could make an appointment with Ms. X for an in-person examination of my broken tooth, but you could not tell me if this would expedite the approval process.

· May 2nd, 2006: I received a fourth dental exam from an associate at Dr. X's office, who took a single x-ray of my broken tooth and assured me that the x-ray clearly evidenced a need for a crown.

· I plan on hand-delivering this new x-ray to your office on the morning of Friday, May 5th.


As you can see from the above timeline, as of May 5th, four weeks will have passed from the time I first provided your office with my authorization request. My tooth has remained partially broken for over four weeks, causing me physical discomfort. A dentist first advised me of the urgent need for a crown over four weeks ago, stressing the real possibility of further damage or infection, which could lead to complications including endocarditis, a serious and potentially fatal heart infection. I have been forced to endure the physical pain and discomfort of a broken tooth, and have been unable to chew food on that side of my mouth for over four weeks.

I work very hard at xxxx Medical Center as a member of the xxxx union, paying my union dues every month and representing the union in my capacity as a social worker with the terminally ill. I have made every possible effort – including hand-delivering my authorization request to your office on 42nd Street, an hour-long commute from my office at xxxx Medical Center – to expedite the review process and receive a dental intervention which three different dentists have advised. It has been more than frustrating to receive inconsistent information and guidance in such a prolonged time period from your office, when I am only trying to receive dental care to which I am entitled and which will have an impact on my overall health and well being.

As a social worker with the terminally ill, I pride myself on my patience and composure, as well as my knowledge of the complications and intricacies of the health care system and its various bureaucracies. It is not easy to “rattle” me. At this point in time, however, I must again advise you that I expect this matter to be resolved as a first priority for your office. Your failure to follow through may result in further harm or damage to my physical person, which would leave me with no choice but to explore legal action against xxxx, an entity whose purpose is to protect me and not to cause me further pain and suffering. This issue goes above and beyond the regretfully inadequate and restrictive level of dental coverage provided by xxxx.

I appreciate your understanding in this matter, and look forward to having this issue resolved in the next week. As always, please feel free to contact me with any questions at (917)xxx-xxxx.



Most sincerely,



________________________
Groom Zilla, LMSW
Social Worker
xxxxx Medical Center
xxxx, NY


Cc: Ms. X, Executive Director xxx NBF
Mr. X, xxxx Organizer, xxxx Medical Center