Dual Insurance Coverage

[rivergirl 12]

I've googled and yahooed and binged and I can't find anything about my strange insurance question. Wondering if maybe someone has a little more insurance knowledge than I?

I am insured by UHC (primary) and Cigna (secondary). Both are self-funded plans by my & my husband's respective employers (I think this may be an important fact). UHC is aware they are primary, and Cigna is aware they are secondary. As many of you know, UHC has a 6 month supervised weight loss requirement and Cigna only requires 3 months. When I first began this process, my husband called Cigna to find out about the coverage. He asked the person if Cigna would still cover the surgery if I CHOSE not to meet the 6 month requirement for UHC. They said that as long as they have a denial letter from UHC or an EOB showing a payment of $0.00, Cigna would then cover the procedure in full.

I didn't quite believe this, so I called myself and explained the situation to someone else - that UHC does cover the surgery, but I would choose not to meet the 6 month requirement. That person also told me that Cigna would cover it in full as long as it is first submitted to UHC, and then the denial letter is submitted to Cigna. I made a 3rd call just to see if I would get a different answer, and I was told the same thing, but they added that since UHC was going to deny it (and it's inpatient) that Cigna would require a precertification.

When I spoke to the business manager at my surgeon's office, she told me I was flat out wrong and that this was impossible. That even though this is what Cigna told me, the precertification was not a guarantee of payment and when Cigna reviewed it after surgery they would refuse to pay it. She explained that if this was because I didn't meet UHC's bmi requirement it would be a different story, but since I would be choosing not to qualify my doing the extra 3 months, Cigna would "absolutely not pay for the surgery".

I called Cigna AGAIN after this and made sure they understood i would be CHOOSING not to meet the 6 month requirement, so UHC would be paying zero. Cigna said, yep, you'll be fine. She looked up my plan and said, "Yeah, you're 'higher allowable' so Cigna would cover it in full as long as UHC processes the claim first and then sends us the EOB showing no payment"

I know something is strange with the cigna plan, because typically secondary plans will only pay the remaining charges after primary has processed and paid a claim. They have been showing the primary payment on the EOB, then what their CONTRACTED payment is (so if the remaining balance is $40, they'll pay $80 because that's they're contracted rate) and then they've been sending us the checks with the overpayment. This has been going on all year we've had the 2 policies, and when we've called Cigna about the checks, they told us they have to pay the contracted rate no matter how much primary has paid.

So, if you've hung in here up to now...here are a couple questions:

- Have you ever dealt with anything like this?

- Can (and will) Cigna deny this when the actual claim is submitted post-op?

- Is there any way to get something in writing from Cigna since we've been told by 4 different people this wouldn't be a problem?

- I know this may not be the typical way a secondary policy works, but is it possible it's because the plan is self-funded?

[sonya139 95]

I'm confused. Why would you not go through the required 6 months supervised weight loss?

[MIJourney 490]

I would get it in writing from Cigna prior to your surgery.

Better to be safe than sorry.

[rivergirl 12]

Sonya, sorry I didn't explain that. If I do the full 6 months,it would put my surgery in 2014. My primary coverage is pretty awful and will only cover $10,000 lifetime. My employer's policy has been covering less and less every year, so there is a good possibility it could be a full exclusion next year. My husband's insurance is secondary and will cover 100%, but they had a policy change last year where if a spouse is able to get coverage through their own employer, their self-funded policy will only cover as secondary. There are rumors that they are changing that to not covering spouses at all if they are able to get insurance through their own employer. We won't know for sure until sometime in November.