Need to get this off my chest~HELP if U can

3loves · April 10, 2006

O.K. I really need to get this off my chest b/c I haven't been able to sleep and I'm trying to stay positive. I finally finished the requested (by insurance per psy eval) 3 support groups and faxed them to NGS American. When I called to verify the PreD dept got it, Patty (PreD dept taking care of my file) informed me that my Psy Eval and Nutritional Eval were incomplete and I needed medical records showing compliance. Knowing my insurance had sent these, I asked her to help me understand EXACTLY what she meant so I can address this with my surgeon.

Here is what I was told:

~ Both evaluations were incomplete and were not favorable b/c they did not state whether I would be a good candidate for the surgery and they did not indicate whether I could follow the lifestyle after surgery. I really don't know if this burden is on the evaluations or if this is a ploy by my insurance.

~ The medical records I submitted from my Optifast last year showed non-compliance. Yes, they did indeed state that on different occasions b/c I was always completely honest if I had something other than the shakes/bars. On these occasions, I was light-headed, shaky, and thought I may even pass out so I would have A cracker or A slice of bread with Peanut Butter. Another time, I ate a piece of cake at my birthday party. Another time I ate 6, yes I counted and put that on my sheet, 6 Frito's just b/c I wanted them.

I told Patty that I do not understand how they can consider this a failure for me since I did lose weight....I lost 32 lbs over 3 mos. She then said, well this surgery is for people that can't lose weight. WHAT?? I thought I was going to blow!! I stayed calm and told her that if I could keep the weight off, why would I be asking for WLS? It seems I am in a no win situation with them.

I then went on to tell her that I have specific records from my family doctor (she confirmed they had them) from 1992 showing different weight loss attempts & I always put the weight back on and more. She said the medical records had to be recent. My records run from 1992 - Nov 2004. We moved to IN in 2004 so I had a new doc. I told Patty that I am very surprised that I need to address such an issue as the non-compliance and that I would go to my grave saying that I did not fail that program. She did try to be encouraging and said that they haven't said no yet, but they would resubmit if I got the new evaluations.

I feel that once I get the evaluations corrected/complete with my surgeons office, they are going to deny me based on my Optifast program and non-compliance. My husband told me I was too honest. Now I'm feeling it doesn't really pay to be honest if this is the game I have to play. I felt I was only hurting myself if I wasn't forthcoming with every little thing I put in my mouth while on the Optifast program. I mean, I told everything every time. What is wrong with me?

Sorry this is so long and thanks for the shoulders to cry on. :cry Any help or advice is sooooo appreciated!! I would have been crying all weekend had I not belonged to this community. I know there is hope and that this is far from over.

leatha_g · April 10, 2006

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Elisabethsew · April 10, 2006

You're going to need the psych person and the nutrition person to each write a letter or an addendum to their reports and send it to the insurance company. You're also going to need a letter from your diet program stating that nobody is 100% compliant put that you were in the top 5% of people who "work the program as designed and intended."

Insurance companies are in the business of making money and will do anything they can NOT to have to pay. Call the company and ask to speak to your case manager so you deal with the SAME person throughout this difficult and trying time. Stay strong.

chichigirl · April 10, 2006

Sad but true, the insurance companies are indeed profit making businesses, they are not for profit charities, so they try to deny as many claims as they can legally get away with.

You have to be consistent, persistent and now matter how infuriating or frustrating it becomes for you, you must not give up. The business I am in deals with nothing but insurance companies on workman's compensation basis. My job in particular is billing, and believe me they are looking with fine tooth combs and telescopic magnifying glasses for reasons to deny a claim. The worse thing they do, if you can believe this, is to deny a legitimate claim, when they are addressed on the issue, they admit to it being their fault, then have the gaul to take an additional 60 to 90 days to pay the claim, the one they made an error on by their own admission. It's enough to make you want to scream, it only takes a five minute phone call for them to check it out and admit to their error, yet it takes 3 months longer to pay the claim they should have paid to begin with. I really think the state insurance politicians should be looking into this unethical practice, but when you call them, they don't seem to care, let alone do anything about it.

If one of us tried to get away with that kind of behavior and pay our bills the way the do, we'd all be put into debtors prison.

I guess I am just trying to help you understand that you are not being singled out, even though it must feel that way. Doesn't change the aggravation it will cause you, but you can win this battle, believe it or not. Just tell them you are not a mind reader and that you want in writing exactly what they are requiring and you will provide it. Then is not a test on your part, so they are required by law to give you the information they need to qualify the claim.

I wish you the best of luck and hope you can get this resolved quickly. This part is actually more difficult than having the surgery, so hang in there and post here often for the support you need. Most of us have had to go through the very thing you are experiencing right now and we survived and so can you.

Cindy

DonnaB · April 10, 2006

Keep pushing the bas*$*rds! They want to beat you down so they can pocket YOUR money and not have to come through on their promise of paying for your healthcare. Don't give up. Stay calm, but stay mad. Don't let them wear you down till you give up. Don't let them win.

Can you tell I was a self-pay for my lapband surgery? Can you tell why?

Mvpo8961 · April 10, 2006

3loves I had been wondering what had happened with your ins. I still dont have an answer yet either. They requested more info from the doc and I guess it hasn't gotten to them yet. I am going to call tomorrow. I hadn't forgot ya and am keeping my fingers crossed for ya. M;)

ReneBean · April 10, 2006

Ah, 3Loves - I had to fight for four months - and I was denied for Lap Band because I was TOO FAT. They will come up with anything they can to avoid paying. Good Luck, and Keep Fighting!

3loves · April 10, 2006

Thank you...thank you....thank you!! You all give me the strength to fight the fight. Worst case, I am willing to go through another 6 mo diet program, but they will NOT beat me down. They may make me cry, but I will not go away.

I just don't know if this would be a legal denial on their part. Also, since we are self-funded insurance, would it help to plead my case at the corporate office....bascially, see if someone would make a call on my behalf to approve the band? I'm reaching here.

Mvpo8961 ~ Thanks! You hang in there too. You are so close and I will keep you in my prayers!

kim2bhealthy · April 11, 2006

Oh my gosh 3loves!!! I wish you soooo much luck! Keep your chin up! Fight til the end... I can definitely relate... I am launching my second appeal to John Deere and appealing to the Tennessee Department of Commerce and Insurance... Man this stuff is so frustrating isn't it? You know what they say about the "squeeky wheel", I'm squeeking my butt off, how about you? They may end up denying me again, but are they gonna get a piece of my mind in the mean time!!! Didn't mean to hijack your thread, just commiserate! Go get um my NASCAR buddy!:faint::faint:

3loves · April 12, 2006

Hey Kim ~ You didn't hijack at all!! This is about all of us that have to fight. After being part of this site, I have heard it all and feel I'm armed and ready. I'm about to pull out a can of pre-menstrual whoop ass on them!! Good for you for staying strong....we will fight together!!

Long story short, I now have an advocate that represents the company my husband works for. She handles insurance for our self-funded company. She was told today that they don't even pay for lapband. What a crock. I have taken notes since day one and told her on 1-9-06 at 2:15 PM I talked to Kathy at NGS and she informed me it was a paid benefit. They also said they didn't have my other medical records. I told her I talked to Keely on 1-22-06 and confirmed they were rec'vd. I sent another copy of my records to NGS with Delivery Confirmation (she said it wouldn't pay to overnight them) and when the mail room gets this envelope, they are to hand deliver it to the manager of the Pre D dept.

Also, thanks to LBT, I was able to also provide her with the procedure code. I told her about all of you. :biggrin1:

She called NGS back and put my file into the hands of management! :clap2: She told them there is no reason for my file to be denied and no reason for me to be waiting this long. She gave them until the end of April to get my file in order and make a decision. She said thinks looked positive and I should be able to get the surgery IF I can get the Psy Eval put into wording of a favorable decision.....it's all about perception. My surgeon's office is going to address this with the psychologist.

Boy, it pays to document. I have every date, time, person, and conversation documented from day one. I guess it's a habit from my admin days that seems to be paying off.

Mvpo8961 · April 12, 2006

:hail: Way to go 3loves!!!!!!!!!!!! I might have to borrow a can of that whup ass myself. M:fencing:

kim2bhealthy · April 12, 2006

Go get um' 3loves! Sounds like your advocate is gonna help you kick butt! Again, GOOD LUCK!!!!

3loves · April 14, 2006

:update:

My psychologist wrote a letter on my behalf recommending me for the surgery and he used the wording they requested and NGS has a copy. I also confirmed they rec'vd my medical records once again. Now my file has been sent to the insurance doc for review for the 2nd time. I asked my advocate what her feeling was and she said they indicated that while I was on Optifast I was able to lose weight. :uwelcome: What the heck? Last week they were complaining about me not being 100% compliant. I can't win for losing!! I may be looking at an appeal. My advocate did tell them that I can lose, but gain it back and she also said the band is to me what meds would be for an alcoholic. If they drink they get sick. The band would be a tool to help me keep weight off. Good analogy I thought.

Should I line up an attorney? Any suggestions for one? We don't have much money b/c I'm a SAHM and things are tight as always. :phanvan Still praying for a positive outcome, but I'm ready to fight.

Mvpo8961 · April 14, 2006

3loves sounds like you are where you need to be. The yoyo weightloss and regaining is one of the reasons why a lapband would be considered. So it sounds to me like you have adequate documentation if it should come to an appeal. But it sounds to me like you have all your ducks in a row. So just hang tight for a little longer. M:)