Issue with surgeon's office... advice?

[achopp 0]

Hi,

I'm having a major issue with my surgeon's office, specifically the insurance coordinator, and I'm not sure what to do about it.

So back on 2/17 my insurance denied my sleeve because it is considered investigational (although they told me the procedure code was covered initially, grr...). I called my insurance after the denial to get more info, and basically they said that I needed to send in an appeal letter, but more importantly they needed to do a peer to peer with the surgeon, and that he had 7 days from the denial to do the peer to peer.

I called the surgeon's office. The insurance girl (who is the only person there who handles this stuff apparently) said that she would give the doctor the info to call my insurance and do the review, and the she would contact me when she knows more. Meanwhile I went ahead an scheduled a surgery date of 3/30 as a self pay. I don't really want to pay for this myself, it's going to take all of my savings, but I have to have the sleeve at this point to improve my quality of life.

Anyway, a few days later I called my insurance to see if the peer to peer had been done yet. They said no, and that it was the 7th day after the denial, so the doctor had to call by the end of that business day to schedule it, or it wasn't going to happen.

I called the surgeon's office in a panic. I asked the insurance girl if she could please, please ask the doctor to call and schedule a peer to peer that day, as it was the last day to do so. She laughed it off, said that the insurance co. would talk to the doctor regardless of when he called, and for me not to worry. Well, the peer to peer never happened.

Unsurprisingly, on 3/2 I was denied my first appeal. I called the insurance girl again on 3/3 to tell her of the denial. She is still telling me that the doctor is going to call for the peer to peer, even though I'm telling her that the insurance company is saying the chance has passed. I email her a copy of the denial letter, she says she will tell the doctor again and call me if she hears anything. Oh, and she has the most annoyed attitude with me every time I call.

I now have one more chance to appeal this before 3/30. I spoke with my insurance co. this past Friday, and they said if I can get a letter from my doctor explaining why he thinks the sleeve is the best option for me over RNY or the lap band I would most likely win the appeal. The insurance co. has to have the second appeal and letter from the doctor within 30 days of 3/2.

So, I'm going to call the surgeon's office Monday morning and speak with the sassy insurance girl again to tell her about the letter I need from the doctor. I know that I'm going to get the same BS blow-off again. I'm so frustrated I want to cry or scream. I've already missed one opportunity with the peer to peer review, I don't want to miss this one.

My question; how pushy can I be with this insurance girl? Do I have any right to demand a letter from the doctor within a specific time frame, or is it at his whim? To be honest, I don't even know if the doctor knew about the peer to peer, or knows I need his help in the appeal process. I feel like ever since I told this girl that I would self pay if I didn't get approved she's been blowing me off.

Short of going to the office begging and crying, I don't know what to do. Any advice?

Thanks,

andrea

ps: sorry so long!

Edited March 14, 2010 by achopp

[Stacy160 201]

Go to the office and ask to speak to the surgeon, and wait there until you do. Tell him the entire story just as you did above; if they can't make it happen, go somewhere else, even if you do still wind up self-paying.

[MINI-Me 196]

Go to the office and ask to speak to the surgeon, and wait there until you do. Tell him the entire story just as you did above; if they can't make it happen, go somewhere else, even if you do still wind up self-paying.

The surgeon definitely needs to know how his patients are being treated. If he doesn't seem concerned, find another doctor!

[wwqueen31 0]

Go to the office and ask to speak to the surgeon, and wait there until you do. Tell him the entire story just as you did above; if they can't make it happen, go somewhere else, even if you do still wind up self-paying.

I would be furious if the insurance coordinator would do that to me. I am a self pay but if in any way shape or form your ins will pay after talking to your surgeon, I would go up there and wait to see him even if you have to make an appointment! Good luck:)

[wannalise 15]

I agree. You are easy to ignore via phone calls, but I'd go and camp myself there until you had some sort of resolution, even if it were merely to file a complaint about the insurance coordinator. Best of luck.

[deedee 5]

I'd call and schedule an appointment with the surgeon in the next couple of weeks. I would not set this up through the insurance lady, but the office coordinator. You could say it's to discuss your surgery options (I'm assuming this surgeon does more than vsg) and at the appointment explain yourself to the surgeon and what you need. Also, you may want to postpone or cancel your surgery date and let them know that you still aren't sure if insurance will cover.

Maybe call another surgeon, talk with their staff and explain the problem...maybe you'd be better off??

Good luck!

[meesa 0]

Someone else mentioned before set an appointment with the surgoen and explain to him your circumstances. Be very persistant with getting the first available appointment to see him. I had somewhat of a similar situation with my coordinators and what I did was emailed my doctor and the nutrionist whom i had build a relationship with and they assisted me(i am getting lapband revision). Do not give up my insurance denied it initially but asked for supporting documentation stating why they felt it was best. Good Luck. Patience

[LAN2k 18]

Patience is key as well as persistence. I am in agreement with all the above. It seems likely that your insurance will cover the sleeve providing they get the documentation from your surgeon. It really is the surgeon you should be speaking to. I had no problem getting my surgeon on the phone. If he was in his office and not in the operating room, he would take my call. If he was out I always got a call pronto that day or the next. If your surgeon does not take you seriously then I'd find another. If all else fails and you decide to self pay have you considered Mexico w/ Dr. Aceves? The point is you have other options and at this point I'd bypass this insurance coordinator altogether.

[achopp 0]

Thanks for the responses guys,

I did actually go there, and made some progress. The insurance lady finally called my insurance company, and the level 2 appeal with my surgeon is going to happen this week. Good to know that some of you have had your appeals won on the second try. I have hope!

[cwalck 1]

GO TO HIS OFFICE! Yes, you have patient rights. Go in person, it will make a big difference.

[LAN2k 18]

If I may add when you go to your surgeons office bring someone with you if possible. I always had my dad by my side or my mother. It holds them accountable. It's you having a witness present. Hope it works out for you.