Denial part 3

[Big Opie 32]

When I originally got the denial from an insurance representative on July 14th, at around 4:00 p.m. CST time, I was advised to contact my bariatric office for more details on how to appeal. I had called my bariatric insurance coordinator, Lisa, at around 4:45pm whom have reviewed the information with her supervisor who then advised me based on the denial I have to go through once a week meetings for 3 months with a licensed psychotherapist, psychiatrist, or psychologist. That was it. That was the end of the conversation.

I slept on it, and came back with questions on the morning of Wednesday, July 15th. I called the next day and asked the following questions. If I can have a copy of what was submitted to the insurance by the psychiatrist, so I can take it elsewhere and get a second opinion. I was told no, it wouldn’t matter because I still had to do the 3 months BEFORE I can appeal. I asked if there was specific information required by the plan for the once a week meetings for 3 months. I was told no. I asked if I could speed up the process by going to twice a week sessions instead of one and completing it within a month and a half instead of 3 months. I was told no. I asked if I could get a copy of the denial information, and also what the psych evaluator had submitted to the insurance, so I could take it to the other psychotherapist and discuss it. She said I had to call the Psych place and request the file.

That same day, I went up and requested it, and long story short, they said they would take care of it by confirming the information with the Psych who submitted the information and would call me back. I get a call that Friday, July 17, 2015, stating that they needed a copy of the denial letter to move forward with their research. Which I couldn’t give them because I didn’t have it to give, I had to wait.

I got the letter on Tuesday, July 21, 2015, late enough in the evening to where I couldn’t contact anyone, but I had the denial letter in hand and I was ready to get the ball rolling. The next day, Wednesday, July 22, 2015, I got up at the butt crack of dawn, did laundry, and called the insurance company around 8:30am to discuss a possible peer to peer, a possible expedited review, and also a possible external appeal through Independent Review Organization at the same time. I was told by the rep, that she’d send the information to me through the mail, but to contact my bariatric office for more information.

I disconnected and called again. I got a different rep, which had bariatric surgery and went over this step for step with me. Told me that if I have my psych evaluator correct the information, or add that I understand the process, and my past won’t hinder my ability to understand the process and follow medical/surgical recommendations, then my provider can call and request a redetermination. Not that I had to go through the 3 month process, which I was so thankful for. All he had to do was call.

Later that morning I went up to the psych’s office and provided them with a copy of the denial letter. I then called their billing office and requested the documents that the psych had submitted AS IS as of this moment. They refused and referred me to my bariatric insurance coordinator for that information, because they don’t have a claim through insurance, and they didn’t submit anything to the bariatric office so how do I have a denial letter. I read it to them.

I told them I gave the office a copy already, and that I, as a patient have a right to ALL medical records according to this denial letter, so I can put together an appeal. She transferred me to her supervisor. Who told me that they didn’t submit a claim to insurance, they don’t even have the evaluation completed by the psych so how could they have a denial. They stated that I needed to contact my bariatric office for what they submitted to insurance.

I called my surgeons office and made an appointment for July, 29, 2015, at 4:00pm to talk to my surgeon because I do not feel like he is aware of all the disconnects between his office and the premier psych. I then called the insurance coordinator. I then again, requested ALL information that was submitted to my insurance, because I have a right as the patient, to any and ALL documentation in regards to the appeal. She stated I’ll have to talk to Premier psych. I told her that I made an appointment with Dr.Winterstein who I don’t think understands the hassle that I have gone through for documents that I have a right to as a patient. That I don’t think he is aware that I’m doing the job of his so called office coordinator, whom is blowing me off and telling me that I cannot do anything until I do once a week sessions for 3 months with a psychotherapist. My letter states differently.

She transferred me to her supervisor, office manager Kristy. Which I explained all the above information to, I advised that the documents that submitted by their office were incomplete and wanted copies of everything AS IS! She stated that he submitted the information with the following information only, “The patient is currently stable on all prescriptions. Patient has not had substance abuse problems or depression issues since 2011.” That’s it. She felt that if she coordinates with them and requests that he submits information per insurance, they can just resubmit not a problem. I advised her that I have a psychotherapist appointment, (July 23,2015) and I plan on keeping them for once a week for 3 months until I have a date for surgery, because it doesn’t seem like anyone can do their job.

Went to the appointment, got a call during the appointment. Checked my voicemail afterwards; which was Kristy, who stated that Dr.O submitted the information completed to their office. She wanted to see how my appointment went, to see if the psychotherapist can submit something that states my past will not hinder my ability to follow instructions of surgical/medical staff. I gave her the number and told her to do it.

That’s where we stand right now. It’s a hot mess. I hate it, but I feel so empowered because I’m fighting for my right, for what I believe, and here is to hoping it gets corrected. I have all my appointments scheduled for Tuesdays at 4:30pm until October 23, 2015, for my psychotherapist. If it does fall through, that will be my last appointment; I will have to set up with my monitored weight loss for August, and September. Then hopefully it will be submitted by October 31, 2015. I’m not getting my hopes up.

That’s my long drawn out update, and the hell I have gone through. Sorry it’s so long.

[Mommabird 367]

I'm so sorry you're having so much trouble with getting approval! Good for you for not taking all this lying down and fighting for yourself!

[The Candidate 3,215]

Man, I'm hoping against hope that you get your approval. Keep going no matter what. You deserve, at the very least, a fighting chance, without having to fight convoluted red tape every step of the way. I am pulling for a win. Good luck!

[Trayjay33 138]

@@Big Opie, your a fighter I love it! Always put that spirit to positive use and don't give up. I saw your other post and I have had reflux and my surgeon wouldn't do the sleeve and instead did the bypass. I know it's something else to add but you don't want to go through an additional surgery. I wish you the best of everything.