I'm SO upset - Insurance denied me -- Need Your Help

cl_tx_42 · September 14, 2006

Well...I got that bad news that my insurance denied me. They said morbid obesity is excluded from my plan. That it is a rider and my company elected not to opt for that option.

Can you fight that?

Another question? My husband's insurance (my secondary insurance) will cover it but there is a $10,000 lifetime maximum. Well...we all know that around $22,000 is billed to the insurance for the surgery.

Someone mentioned a doctor in Colorado that does the surgery for $9950 - do anyone know how much he bills for the surgery?

Any other suggestions? (Self Pay is not an option)

Heck, I'll even change jobs just to get it to be covered by insurance. Willing to work in the Houston or Beaumont area :girl_hug:

Constance · September 14, 2006

Hey Cheri. I'm sorry about the denial. I was denied too. Check out the Insurance forum here. You will find many others going through the same thing. The doctro in Colorado is Dr. Kirshenbaum. He does not work with insurance typically. That rate is self-pay. You shoudl consider contacting ObesityLaw.com. Walter and Kelly Lindstrom are the lawyers and they have a great success rate. It is cheaper than you would think to retain their services. I decided to go self pay -- but if I couldn't have, I would have used Walter and Kelly. Best of luck!

want2lose · September 14, 2006

One other thing to consider. The $10000 max might work, since the insurance companies alway pay the "usual and customary" fees, not the full cash price. The Dr's that take insurance are accustomed to this. You might be able to call your insurance company and see if they can tell you an amount. Will your insurance company cover pre-op testing? That could also help you spread it around.

wantlapband · September 15, 2006

I was denied today also :think. My surgery was next wednesday the 20th. I am so upset right now.

My doctors office is faxing them over some more paperwork to see if they can reconsider before appealing. My BMI is 35.2, 207 lbs. I have heart disease and other factors. I had two letters one from my cardiologist and one from my primary stating that.

I have no idea what to do.

Self pay is not an option.

How do I use obesitylaw.com lawyers?

Do you know how much it is?

It might be worth it.

I just didn't want to want sooo long to have surgery.

I have been counting down the weeks...

I HATE THIS...I just want to crawl into bed and cry and never come out. I'll be crying all day long..:think:think:think:think

Thanks for listening and support and help.

Debbie

shaunaruder · September 15, 2006

I am a medical biller. First of all, do not EVER accept the first denial from an insurance company. Sometimes it may take even 3-4 times for an insurance company to okay your surgery. Submitting ALL medical records helps.... One thing I have found is that if insurance denies the surgery as it is excluded then they will more than likely not pay no matter what you try. Depending on your doctor, they may choose to submit it to your secondary, but they wont pay either until you submit it to your primary. So they would have to submit it to your insurance, receive a denial, then send the claim along to your secondary insurance with the primary denial eob. Secondary's usually do not pay even half of what the primary would pay so that would be something to check on.

The price for the surgery may be around 22,000 but you have to take in account that half of that will be written off by the doctor and facility. Making the total amount paid by insurance to be around 10,000. But it all depends on what the actual fees are for your doc and facility. Another thing is that your insurance may say that you, the patient, owes a copay amount, which would lower the amount that they pay too. An insurance that only has a $10,000 maximum is more than likely not going to pay much. Im sorry.

NancyRN · September 15, 2006

Shaunaruder,

Thanks for letting us know about your expertise in medical billing. I have a billing-related mystery that has flummoxed me. Would you help me?

I'm in the preop phase for a lapband at the University of California, San Francisco, Bariatric Center. I'm trying to get a ballpark figure on what this surgery is going to cost me.

When I asked my surgeon's office manager, she said she didn't know and referred me to the UCSF billing office. The person there told me the lapband surgery costs $84,000 plus an additional $9000 for the surgeon -- $93,000 total. :omg:

I know the billed amount is irrelevant. What's important is the particular insurance's contract with the center.

When I told the billing woman I needed to know the contracted rate, she acted like she'd never heard of that idea. :rolleyes (Maybe no one ever was savvy enough to ask her before.) She said she'd have to talk to the contracts office and would call me back. And, of course, she never did.

So where do I go from here? My sense is that continuing to pursue it within the university is just going to be a bureacratic runaround. I thought of calling my insurance company, Blue Cross of California, but who would have this information?

Also, BC has told me they'll cover all my preop tests if they're medically necessary. I've gotten burned before, when a doctor has thought a test was medically necessary but the insurance co. rejected the claim, saying it wasn't. Is there anyway to be sure the company will pay for them, before I actually have the tests and become financially liable for them?

NancyRN

wantlapband · September 15, 2006

I talked to my surgeons office today after my denial letter came in the mail...only took them one day since they rec'd my paperwork. She was very upset also.

She looked at all my co-morbid letters from my doctors. She talked to the surgeon, and he got on the phone with Anthem (NH) and they OVERTURNED my denial!! I am APPROVED!!!! Just like that!!! OMG...I am soooo happy.

My surgery is still next wednesday, just don't know the time because they had to cancel my first time.

I AM SO EXCITED!!

I will keep you all posted! :clap2:

cl_tx_42 · September 15, 2006

Wantlapband:

What was the reason for the initial denial?

derbygirl · September 16, 2006

Cheri,

I am in Texas also and was denied because it was excluded. It's my understanding that there are several states which allow employers to add these exclusions to lower the price of their premiums. Some states, like California, DO NOT allow employers to exclude weight-loss surgery (among other things). When I found this out, I was ready to leave Texas. But my family is here.

If you are serious about changing jobs, look for a nationwide company that is NOT BASED in Texas.

I'm not saying that all Texas companies agree to exclude, but since it saves them money on premiums, they tend to do so.

I originally told myself that self-pay was not an option. You might try re-evaluating your priorities. I generally buy a new car every 4 years or so. That's about $20,000. All I have to do is drive a junky car for a few years!!!

libra · September 16, 2006

Wantlapband, good for you!! I'm glad it worked out for you.

Don't give up. Keep pounding the insurance company with information, keep calling. Do whatever you can. Best of luck!

Lila · September 16, 2006

Congratulations Wantalapband

What great news!!:clap2: :clap2:

wantlapband · September 17, 2006

Wantlapband:

What was the reason for the initial denial?

The initial denial was I had a BMI of 35.2 with no life threatening co-morbities...my I do, there were two letters stating I had heart disease, one from my cardiologist and one from my primary. So my surgeons assistant got on the phone and called Anthem (NH) and it was overturned..I believe the surgeon himself spoke to the medical director that decides at the insurance company also.

My surgery is still on for September 20th! There were still able to take me that day.

Don't give up!

lpbndinfo · September 18, 2006

Cheri, I also live in texas... I can tell you about my experience if you want... I had the band done 8/26/02 and debanded 1/6/6 and now I have the gastric sleeve... Let me know

patti

bandinfo@verizon.net

shaunaruder · September 18, 2006

Shaunaruder,
Thanks for letting us know about your expertise in medical billing. I have a billing-related mystery that has flummoxed me. Would you help me?

I'm in the preop phase for a lapband at the University of California, San Francisco, Bariatric Center. I'm trying to get a ballpark figure on what this surgery is going to cost me.

When I asked my surgeon's office manager, she said she didn't know and referred me to the UCSF billing office. The person there told me the lapband surgery costs $84,000 plus an additional $9000 for the surgeon -- $93,000 total. :omg:

I know the billed amount is irrelevant. What's important is the particular insurance's contract with the center.

When I told the billing woman I needed to know the contracted rate, she acted like she'd never heard of that idea. :rolleyes (Maybe no one ever was savvy enough to ask her before.) She said she'd have to talk to the contracts office and would call me back. And, of course, she never did.

So where do I go from here? My sense is that continuing to pursue it within the university is just going to be a bureacratic runaround. I thought of calling my insurance company, Blue Cross of California, but who would have this information?

Also, BC has told me they'll cover all my preop tests if they're medically necessary. I've gotten burned before, when a doctor has thought a test was medically necessary but the insurance co. rejected the claim, saying it wasn't. Is there anyway to be sure the company will pay for them, before I actually have the tests and become financially liable for them?

NancyRN

Nancy,

WOW!! That is an absolutely outrageous amount for a lap band. I have never ever heard of the price being that high. What you could do is talk to one of the billers at the facility. Since they bill for the surgery every day they should know off the top of their head what the contracted amount is for the surg. If the office manager or lady you talked to doesnt do billing then she would really have no clue what you are asking for. If you know what they bill the insurance then you can figure out what they will pay by calling your insurance company ( or looking at your policy) and find out what percentage they pay, whether its %50 or %80. There will be a write off amount that cannot be billed to you, that is usually based on the amount paid.....Your best bet is to talk to a biller, calling the insurance and asking them about probable bill doesnt usually fly and will not really get you any where.....

finallyonmyway · September 18, 2006

Hello everyone,

This is my first post. I was also denied by my insurance. Turns out the surgery was an excluded procedure on my plan, so I did not attempt to fight it. I had researched having the surgery done abroad, and that's what I did. I was banded in Monterrey, Mexico on 9/1/06 for less than half the price of what it would have cost me in the States.

For anyone who can afford to finance the procedure - I would recommend this hospital and can refer you to their web site. Overall it was a very positive experience, and I'm doing very well two weeks out.