Waaaa ;( Need Your Opinion

[heartonmysleevey 133]

Hey everybody!

I havent been around for while because of how sad I have been. But today my big sister told be to get off my butt and take care of business.

I have been doing my supervised diet with my pcp since May. As of November 6th my 6 months is up and all of my qualifications have been met. Last minute my pcp said I need to go to more classes for 6 months to another medical group that is 45 minutes ( one way) away. Classes are once a week for the first 3 months then twice a month for the last 3. At first I was shocked and mad. I have posted about this issue before. But now I have more details.

After being upset, I came around. But I still couldn't get to the classes. I have a 5 year old and a 1year old. My husband comutes and I have a hunk-o-junk car. Plus, gas money. oh yeah, Im a stay at home mom. So, now im not upset about the time. Im upset that I can do the classes. So I told that to my PCP. I said if classes were local I would have no problem.

Next problem, I asked for a referral to see the surgeon that I picked so maybe they could push the surgery. ( i have met and exceeded all of my AETNA *** requirements.) My pcp said that the medical group has denied that request as well. WTH!!! If i had a referral to see my surgeon , they could submit all of my paper work and I would have a date. Im %100. I have read Aetna obesity policy bulletin 10 times! I never received a denial letter for my referral. I feel like my PCP does not want me to have surgery and that she never EVEN submitted a referral request.

This is where my sister come into play. She know Doctors and has work in doctors offices for years. She thinks the medical group wants to drag it out to the new year. Every year I believe they get a lump sum of money for me being with there medical group.

I wrote a letter that I am mailing certified tomorrow to my pcp. All i want in this world is a referral to my surgeons office!

Here is the letter:

To whom it may concern;

This is a formal request in writing. To my understanding, I have been denied a request for a referral to see Dr. J******. I do not know the reasons for the denial. This is my second attempt in receiving a referral.

Based on Aetna, I have met and exceeded ALL of the policy bulletin requirements.

I have contacted Aetna and they don’t understand why your office is WITHOLDING my referral.

In addition, I was told that Dr. **** was not contracted with ***** Physician’s. I have verified with Aetna and **** Surgery’s contract manager that Dr. J***** IS in fact contracted.

I personally feel my condition worsening and need to see a specialist. This is urgent and I would appreciate a prompt written response for my referral to See Dr. J********.

Attached is a copy of Aetna’s Obesity Surgery Policy Bulletin.

Kind regards,

What are the laws about medical groups and them making up there own rule and completely ignore Aetnas policys?

Where is my denial letter?

thank you all for reading this and your responses :smile1:

[Qpdsful 2]

If you have a PPO and a great Bariatric Surgeon they can get the pre auth without any PCP.

It is all in the packaging and your surgery should be approved if your BMI is off as well. I had my surgery completed and authorized in 4 days!

Don't be upset grab the bull by the horns and welcome the new change!!

[Finding MeMe 204]

Hi Nadashad,

OK here is my opinion, honestly what I would do is send the letter to the president/vice-president or better yet, the supervisor of the individual who is denying your request. This is what I call an (Exception to Current Policy). I would make a personal plea and explain your situation in detail to them. For example, you discussed the shift work and child care situation, the fact that you are a stay at home mom, the condition of your car and the price of gas to commute to and from the meetings. Discuss the hardship that this will cause you and how let down and disapointed you feel about them changing the rules for approval after you have done what was required. Explain that your condition is worsening and the fhe fact that it is just unfair to treat you in this manner. Coming from an HR professional your letter sounds combative and demanding and dosen't contain the details to make the decision you are seeking. Recommend to tone it down a little and put more of your personal feelings and how their decision has affected you and what they can do to assist you in achieving your goal of surgery. :aureola:

[heartonmysleevey 133]

Hi Nadashad,

OK here is my opinion, honestly what I would do is send the letter to the president/vice-president or better yet, the supervisor of the individual who is denying your request. This is what I call an (Exception to Current Policy). I would make a personal plea and explain your situation in detail to them. For example, you discussed the shift work and child care situation, the fact that you are a stay at home mom, the condition of your car and the price of gas to commute to and from the meetings. Discuss the hardship that this will cause you and how let down and disapointed you feel about them changing the rules for approval after you have done what was required. Explain that your condition is worsening and the fhe fact that it is just unfair to treat you in this manner. Coming from an HR professional your letter sounds combative and demanding and dosen't contain the details to make the decision you are seeking. Recommend to tone it down a little and put more of your personal feelings and how their decision has affected you and what they can do to assist you in achieving your goal of surgery. :aureola:

If you have a PPO and a great Bariatric Surgeon they can get the pre auth without any PCP.

It is all in the packaging and your surgery should be approved if your BMI is off as well. I had my surgery completed and authorized in 4 days!

Don't be upset grab the bull by the horns and welcome the new change!!

thank you both for your replies. I want a fast response. I feel this may be my only option. I just wonder if my medical group only calls the shots. I bought a health plan from aetna. Just so confusing. :/

[Qpdsful 2]

Any updates on your appeal?? From a standpoint of the insurance it is imperative that all looking for approval first and foremost find out what the guidelines of that said policy is. Vertical Sleeve is fairly new to insurance companies and they must see a benefit OR your medical office must have great people in place. You as the insured have rights and are protected and may appeal anything however INSURANCE IS DESIGNED AS A TOOL TO HELP DEFER YOUR OUT OF POCKET PORTION. INSURANCE COMPANIES ARE IN THE BUSINESS TO MAKE MONEY!

Make sure your appeal outlines the facts, take your emotions out of the picture..it is similar to law! Of course because this involves you, your future, your life, your health it is very challenging to remove those emotions.

Your bariatric surgeon should have people in place to deal with the insurance company contracted with your plan or not. This is a full time job for a truly dedicated individual.

As an anesthesia coordinator I deal with insurance, patients, and emotions everyday...so I must be very frank when I treatment plan, and when dealing with insurance there is no emotions just straight facts. How you FEEL or what your going thru has nothing to do with the situation.

Your BMI

History of family health issues directly related to morbid obestiy

Psychological evaluation

Past attempts that have failed

Health benefits to having surgery

Your true dedication and proven track record!

Hope this helps...you are welcome to inbox me and I will try my best to help you navigate your surgery...with regard to your comment about purchasing a plan from Aetna that has nothing to do with the politics your experiencing. You must read the fine print perhaps your individual plan does not cover bariatric surgery. If your near San Francisco you may try Paul Cirangle MD he has the right people in place to expedite your insurance delays...and is a very strict to the point amazing surgeon!

Cheers Carrie