lisa0617 54 Posted June 25, 2015 My insurance is being sketchy with my physician. They told them that the information is online but the information is vague. I am waiting for my sleep study so it may not be an issue but they want to know the criteria. I don't want to pay out of pocket if my insurance covers it. Share this post Link to post Share on other sites
Stevehud 1,790 Posted June 25, 2015 you can always call them yourself. By law they must give you their guidelines for coverage. Share this post Link to post Share on other sites
lisa0617 54 Posted June 25, 2015 I have called 3 times they told me to have dr call Share this post Link to post Share on other sites
NikkiDoc 312 Posted June 25, 2015 If your insurance is through your employer then you need to go to HR and complain Them telling you, the customer, to have your doctor call to verify benefits is not acceptable. Call them again and ask for a supervisor or manager if they refuse to answer. I would be livid if they refused to answer if a sleep study was covered and at what benefit level. If push comes to shove you can always threaten to contact the Department of Insurance to file a complaint. (If it isn't an ERISA employer based plan). The DOI complaint won't get you the answer faster but the sometimes the threat will get them to respond. Share this post Link to post Share on other sites
Miss Mac 6,262 Posted June 25, 2015 I lovvvvvve going over peoples' heads. It is so empowering - and it gets things done, especially if you threaten to sic a regulatory agency on someone's upper management. Registered letters copied to either the agency or your state's Attorney General get it done, too, because someone has to admit that they received it. Share this post Link to post Share on other sites
lisa0617 54 Posted June 25, 2015 Its not the sleep study that is the issue its the surgery Share this post Link to post Share on other sites
lisa0617 54 Posted June 25, 2015 I got information on my deductible what they cover for services but the criteria is secret even to my doctor. They just wanted to know can the submit now or do they need me to have sleep apnea. Do I need to have 40 bmi or is 35 ok? I am frustrated. I had issues with the sleep study which I am taking tonight. I just want answers. Share this post Link to post Share on other sites
NikkiDoc 312 Posted June 26, 2015 Even if it is the criteria for the WLS that is "secret" instead of the sleep study my answer is the same. Escalate to HR, insurance company supervisor or manager, department of insurance. Out of curiosity what insurance company is this? Share this post Link to post Share on other sites
lisa0617 54 Posted June 28, 2015 I will have my study back on Wednesday so if they don't call my physician by then I will ask to speak with a manager. Share this post Link to post Share on other sites
BizzyB 119 Posted June 28, 2015 I just looked up their medical policy on WLS - yes, it is very, very vague! It lists no clinical criteria at all. However, it does references Interqual (this is a program that houses criteria that needs to be met). Your doc may have access to Interqual? Doctors offices often contact insurance companies for their criteria and interpretations of policies, that shouldn't be too out of the ordinary - this helps the doctors office to know how to bill in order to have it covered. If you continue to run into difficulties even with a manager in customer service- you may want to ask for someone in Medical Policy or a Medical Director in Medical Management. I work in medical policy for an insurance company. Share this post Link to post Share on other sites
lisa0617 54 Posted June 28, 2015 The provider goes to the interqual site and answers questions and based on the answers give a denial or acceptance. The criteria is a secret because they don't want the public to know. I do billing for a Bariatric surgeon. I am going to try again next week. Share this post Link to post Share on other sites
BizzyB 119 Posted June 28, 2015 What a mess! That is certainly shady... just making members jump through unidentified hoops to get care. Hope you are able to get the info you need from the insurance company! Share this post Link to post Share on other sites
lisa0617 54 Posted July 3, 2015 Fallon faxed the criteria to my dr. I don't know what it is but at least now they know. Share this post Link to post Share on other sites
