Understanding Insurances

[MelindaG 0]

Hi, I'm Melinda, a 47 year old social worker and nursing student. I have contemplated weight loss surgery for years, but didn't have the right supports until now. My family is amazingly supportive, and I have done so much research and questioning of myself that I know it is the right time to go through with the surgery.

I contacted my insurance company (CDPHP ***), and they sent me their policy. Based on this information I qualify. I was referred to a specific doctor by my nutritionist. First the insurance company told me the doctor was covered, but not the hospital they work out of. The doctor's office then said that the doctors also go to another hospital, and that one was covered. I was so excited! I made my appointment, went to the information session, had my first meeting with the doctor, and he felt I was an excellent candidate for surgery. He gave me my to do list, and off I went to get my medical clearances.

I have met with pulmonology, cardiology, psychology and nutrition. I have had x-rays, pulmonary function tests, atrial blood gas tests, x-rays, and blood work. I have a couple more follow ups, but all appointments seem like they will be done by the end of June. I have worked very hard getting all this done in a timely fashion, because I start my nursing clinicals in September, and wanted to have the procedure completed before then.

Just to make sure I was on the right track I called the insurance company to make sure I wasn't forgetting something. This is where they almost broke my spirit. The customer service representative told me that my initial information from them was wrong. My surgeon is approved by them, but not for weight loss surgery. The hospital is approved, but not for bariatric surgery.

I now have to find another hospital, and the closest ones are about an hour and a half to two hours away from me. The prospect of having to go through all of the meetings and tests again seems daunting. I am a single mom and I work full time. I have already had to take a lot of time for all of these different appointments and I don't know if I can do it again. I suppose I can speak with the doctor to see if he will accept the test results.

Last night I cried. It has been so stressful getting everything done, and now it appears its all been for nothing. On the other hand, I can't give up. I want to be healthy and energetic. Does anyone have any ideas? Where do I go next, to the doctor or the insurance company? Thank you for your time....

Melinda

[sarsar 824]

Don't give up, up CAN do this! You came this far to stop now!

This is what I would do if I was in your situation. I would call the insurance company back and talk to a supervisor to make sure the information the rep gave you is correct. Then I would have the dr. office submit your information. The people who decide are the ones who will give you the real answer. If they deny it then I would appeal. Keep notes and write down everything in the appeal letter. If they still deny it then by all means go to another doctor. I would think that they would be happy to accept the of the tests you just had done.

You can also check out the insurance forum on this site. I am sure there are people there who have gone through the same things. Best of luck to you...don't give up!

[former_vbg 198]

This is just my 2 cents, but.... I am having surgery out of state and ALL of my pre-op tests have been local for me. I had to actually switch Dr.'s 2 weeks before surgery scheduled and the new Dr. never even hesitated on reviewing my results done locally- neither did the first Dr.

My point is that you shouldn't have to redo all those various tests they had you do because having them done under a different Dr. won't change the outcome of your results. I worried about the same thing because taking so much time off of work is an issue for many people.

You didn't mention who your ins company was, but most insurance companies have their policy bulletins online and they also usually have searchable databases where you can check yourself which hospitals are in network/ out of network, etc. I've never heard of a hospital being "in network" but not for a specific procedure. That sounds a little odd to me.

Good luck!