Waiting to Exhale

[mrsmith901 18]

Called insurance again and they have still not received my claim. Called the program and there are no notes saying the claim had been sent. The insurance person Kelly, has not returned my phone call of last week and Doreen who is the admin for the program said she would talk to Kelly and see what the hold up is. This is so frustrating. It is almost 3 weeks since my last NUT visit and the program has not even submitted my paperwork. I am about to become that squeaky wheel!

This is kind of weird but lady at my surgeon's office submitting my paperwork's name is Kelly and the admin is also Doreen lol! I am in the exact same boat you are. They STILL have not submitted my paperwork!

[Mrs. Reid 392]

Your better then me. I'm calling daily. I have no time to waste and I'm on a tight timeframe.

I will do every other day next week and if I don't get what I need then I'm going to call the surgeon's directly and tell him what is happening. I bet they will call me back after that!

[Mrs. Reid 392]

Called the hospital today and they have submitted my paperwork for insurance approval!!! Yeaaaaaaaa! I will call back next Friday morning if I have not heard from them. It's a shame I have to stay on top of them like this or risk falling through the cracks.

[time4change15 15]

I am in the same boat....in terms of waiting on approval...my documents were just submitted last week but I am the worst when it comes to being patient. I am ready to go! I can't get a surgery date until my insurance approves my claim. This is the worst part so far...I will pray for urgent responses and patience for all of us! lol

Edited January 11, 2015 by time4change15

[mrsmith901 18]

Cigna officially has my claim now. This waiting is the hardest part hands down!

[della street 213]

Waiting is the WORST. Because your life is totally in the hands of other people doing their job. Here's a very brief overview of my insurance saga - reposted from another forum:

I don't know if I have the time or mental energy to tell the highlights of my insurance story, but here goes in the Cliff's Notes version:

--Hubby's work policy has specifically excluded WLS for at least 10 years

--Last fall (early Oct), I looked into purchasing a policy for just me on the Affordable Care Marketplace ("Obamacare")

--I'm in AZ, and all Marketplace policies must cover WLS -- not a well-known fact. I think it's 23 states ACA policies must cover WLS. Who knew? A fluke I found out...

--Found a policy thru BCBS of AZ that costs about $600/month, but we save about $200/month by not included me on hubby's work policy. Expensive, kind of, but $3500 out of pocket max, after that, all is 100% covered.

--Waited for open enrollment; purchased policy

--BCBS sent me bariatric guidelines -- said 8-week pre-op diet; covers band, sleeve or bypass

--Surgeon's office said have to do 6-month dr-supervised diet. Went round and round w/them since BCBS told me 8-week diet, not 6 months.

--Yada, yada, yada -- finally, BCBS told me that they accidentally gave me the wrong guidelines.

--UGH UGH UGH

--'Real' guidelines say 6-month dr-supervised diet (which I'd done elsewhere, so that was ok for me), but only cover band and bypass, exclude sleeve. I have no idea why.

--I get everything set up w/surgeon's office, have them change my file from wanting sleeve to bypass. They confirmed they done that so when submitted to BCBS, it would say bypass since they don't cover sleeve on my policy.

--Surgeon submits paperwork, I get call that my sleeve is approved. Yes, sleeve.

--Dead silence on my part, then I ask 'so they now cover sleeve on my policy?"

--Surgeon's office: "yes, they've specifically approved sleeve." I said, BUT IT'S NOT COVERED.

--Surgeon's office checks w/BCBS again and lo and behold, sleeve is not covered. they were extremely apologetic, but I could have had sleeve surgery and they could have said 'oops', you're not covered for that!!!!

--Plus, my surgeon's office had confirmed they'd changed my file to say bypass, but they obviously hadn't, and submitted me for sleeve (mistake) which BCBS approved (mistake)

--Bottom line: Bypass surgery scheduled later this month

--PS: just received "approved for sleeve" letter from BCBS in the mail. OY!!!

--Other bottom line: YOU have to be in charge of everything and know what's covered, what's not, get it all in writing, and triple-check EVERYTHING. Not to discourage you AT ALL, just offering advice.

Feel so very fortunate to have bypass covered, but what a huge hassle!!!

I keep a spreadsheet of "to do's" and who I spoke with, etc. Names, dates, etc.

[peteyrulz 82]

@@della street Thank you for posting! There's so much in this process that is contingent on humans being able to do their jobs right...human error plays a huge role in this process doesn't it? I've been futzing with BCBS since March. Now in external appeal. I'm ready to throw in towel & head to sunny TJ! Good luck to you, keep us posted.

We should all write a book: Adventures in Bariatric Sleeve Approval: Fun with Insurance!

[della street 213]

@peteyrulz -- lol! Best of luck to you too!!! Hang in there! I just keep thinking someday, I can be hanging on a sunny beach and feeling normal-looking and remembering all this as being part of the distant past...

[Sharon1964 2,530]

--Plus, my surgeon's office had confirmed they'd changed my file to say bypass, but they obviously hadn't, and submitted me for sleeve (mistake) which BCBS approved (mistake)

--Bottom line: Bypass surgery scheduled later this month

--PS: just received "approved for sleeve" letter from BCBS in the mail. OY!!!

--Other bottom line: YOU have to be in charge of everything and know what's covered, what's not, get it all in writing, and triple-check EVERYTHING. Not to discourage you AT ALL, just offering advice.

Feel so very fortunate to have bypass covered, but what a huge hassle!!!

I keep a spreadsheet of "to do's" and who I spoke with, etc. Names, dates, etc.

Just in case anyone else is in this same boat, once you receive an approval for a procedure in writing from your insurance company, if they do NOT rescind the approval before the procedure and you still have coverage, they are required by law to cover the procedure. You do NOT have to pay for the insurance company's mistakes.

When a doctor receives a denial from the insurance company for a procedure (surgery) as "not a covered benefit", the paperwork always says "if you have an authorization for these services, please send a copy to (wherever) for reprocessing of the claim."

[Sharon1964 2,530]

Also, just in case you get a newbie when you call the insurance company, make sure you use the terms they use.

Claim: Request for payment for services already performed.

Authorization or Pre-authorization Paperwork: Documents asking for authorization to perform a procedure.

If you call and ask if they have received your "claim" for WLS, they may think you are asking about the surgeon's bill, instead of asking about authorization.

I've worked in medical administration for about 20 years, and occasionally I get a newbie when I call an insurance company and have to educate them about what I'm asking.

[della street 213]

@@Sharon1964 Thanks -- great info -- I did get a letter approving sleeve -- I'm assuming I'll get another one disapproving sleeve and approving bypass. The letter says "we've approved the above services. Approval is based on what we know about you, your benefit plan and the planned service. This approval is not a promise of payment. We can't be sure about payment until we get a claim telling us what your provider really did for you. Once we get the claim, we can tell if the service is covered under your plan."

Oy.

[Sharon1964 2,530]

That "not a guarantee of payment" thing is standard. Some people cancel their insurance but figure since they have an approval, they can go ahead and have the procedure and it will be covered. Ummm, no. Regarding authorizations, the law is on your side.

[Catherine Gray 11]

Yay for everyone's paper being sent. BCBS FINALLY got my paperwork friday. So now I wait for a denial so it can be sent to secondary. Then I get to wait all over again.

[sarah-tiffany 10]

Wow!!! That's a lot of bs to go through! I've only just begun, but I'm exempt from six month wait due to bmi over 50, so at least I can check that off the list. I've spoke to 3 different BCBS agents, and all three have informed me that yes, all my costs, 100% will be covered after I've met my OPM...(even though wls surgery has a 50% coinsurance)...BCBS says doesn't matter, once OPM is met all approved procedures covered in full. WELL...the coordinator at surgeon's says she's not seeing that info on my policy. For the love of God!!!! Is it too much to ask if I can get a straight and consistant answer as to if I will be paying 1000...OR 3000?!?! That's quite a chunck of change...not like I have a couple extra thousand lying around! Hoping I'll find out more as the process gets further in. Glad I'm not alone in the insurance cat and mouse game! Good luck to everyone still waiting!

[kyrickchick64 468]

Yeah insurance companies are more than willing to take your money. Good know they don't use it to train people to do their jobs. Ive been fighting for two weeks with Cigna tele drug(the absolute worst ever but the only option I have) trying to get my husbands New drug and insulin. Omg I swear I feel like Denzel in that movie where he takes over the hospital because he's fighting for his son. These people don't know their elbows from their asses. I blame them for my high bp lol