Insurance gave Dr wrong coverage info?!

[jenjackson 4]

I have been going through the process for the VSG since April. The first step was getting insurance coverage information. When my dr office talked to the insurance company they were told that my insurance company would cover the surgery and gave them the requirements. I have since had multiple visits with my surgeon, nutritionist, classes, EGD, 2 psych consults and sleep study. I have a CPAP machine now as well.

I decided to give my insurance company a call since we were still waiting for the approval, just to check the status. I was informed this afternoon that my surgeon was given wrong information and that surgery is not covered under any circumstance and not for any reason. I was completely flabbergasted. I missed work, had one hour drive time each way for all of my visits, I owe hundreds in co-pays for everything, etc.

The manager I spoke to said that she is going to pull the phone conversation to see what was said to my dr office during the initial call, but I am very nervous that it doesn't matter and they won't make an exception. She did say that sometimes they will make exceptions when mistakes are made but I am so worried they won't.

I have worked so hard and been in the process for so long and now I just feel completely defeated. I have no idea what to do. They said they would call me back on Thursday to let me know what they found out. I am going to be praying A LOT until that phone call comes.

Has anyone ever experienced this???

Jen

[Elode 8,093]

@@jenjackson Wow that's horrible! I hope they do make the exception for you, I know I would be furious had that happened to me! I'm always afraid of stuff like that, that's why I called and bugged the crap out of the insurance company to make sure EVERYTHING was correct. I found multiple issues. Heck I even went through it with my dental yesterday when the orthodontist finances lady called them for coverage they said my braces weren't covered. I was right back on the phone with them immediately and found out the person they had talked to didn't even bother to check my coverage just said it was not covered when in fact it is so I stayed on the line while they called my orthodontist and gave them the correct information. You really have to watch them, I know we shouldn't have to do all that but you just do. I will send prayers your way and hope this turns out in your favor. Document every phone call ect.....

[Risabe 3]

I just want to say that I am SO sorry this is happening to you. I hope and pray it will work out. If you self-pay your insurance they really owe you bigtime, and even if you don't I think they should follow through. That isn't right to do to a customer.

[jenjackson 4]

Thanks ladies. I did my own research before I called the dr office to get the ball rolling and I didn't see any exceptions to the surgery being covered. So, when the dr also said it was covered, I didn't think another thing about it. We pay part of our premium through my husband's employer, but not 100% self pay to them. All that I know is that they will definitely have a fight with me because I am not going to be giving up easily. I am going to fight for my ability to have the surgery and for my health. It is all just so wrong.....

[Daisee68 2,493]

This is awful! I am so sorry! Is the insurance through your employer? If so, maybe your HR dept can help you? Either way, you should be able to access your policy in full IN WRITING to see what it says about bariatric surgery. If you do not find an exclusion, then they need to point you to exactly why they are denying the coverage (i.e a copy of the exact exclusion). Remember that each insurance policy is different. In other words, just because I have Cigna (for example) and it covered it, doesn't mean if you have Cigna that they will cover it. When I called, they told me about 50% of their policies cover bariatric surgery and 50% don't. Now having said all that, just know that even if they do have an exclusion in writing that they can point to, they also have to publish appeal procedures and you may need to follow those procedures to a T to try and get it covered. And don't just try once, if you get denied, try again. Someone posted the other day about how they got approved on what I think was their 3rd appeal. I think I would also contact your doctor's office to get a copy of the conversation they had - at the very least date and time - but if you can find out exactly what they told the dr office even better.

Still doesn't take away the frustration and disappointment and I completely understand that, but I just wanted to throw out some ideas of what your next steps might be and hope having a plan gives you some hope!! Best of luck to you! Keep us posted!

[tera1982 194]

I'm so sorry:-( I really hope everything gets straightened out for you soon!!!!!

[Miz.Phenom 32]

If they said it was covered. It's called binding coverage. I work for an insurance company and I know if we tell someone something is covered and isn't we have to pay for it. Maybe it's the same for health insurance? Good luck.

[Sweetsarah7880 2]

Something like that happened to a friend of mine. She went to 3 out of 6 nutrition classes and then found out that the only bariatric surgery was the band. She really wanted VSG so she just quit all together. She has however lost about 50 pounds on her own in the past 6 months since then because of what she learned so all was not lost.

[Sharon1964 2,530]

Do some searches on the topic. There have been a couple of people that have gone through this and the insurance did end up covering it.

[1SlimmerMe 122]

Try these links:

http://www.bariatricpal.com/topic/342863-cigna-really-screwed-up-this-time/page-2

http://www.bariatricpal.com/topic/334629-bcbs-carefirst-horror-story/

The best to you!

Praying...

Edited August 26, 2015 by 1SlimmerMe

[jenjackson 4]

So I got up this morning with a new sense of determination. I talked to my mom for a long time on the phone about it and she gave me some suggestions as well.

I called my surgeon's office this morning and talked to the girl who does the insurance confirmations and she was completely shocked that they would tell me this information. She said that she always gets confirmation numbers from the insurance companies when she gets the approvals. She took my number and is looking into the issue and is going to be giving me a call back today hopefully. Tomorrow at the latest.

I have decided that I am not letting this go. I have worked too hard and gone through too much to have it denied now. If they don't give me the approval I am going to make enough noise that they will have to do something. My mom suggested contacting the news about the crooked insurance system and if it comes to that, I will. After reading some threads on this forum though, I think that if I stand my ground they will fix the mistake and make the approval.

Thank you so much for the words of support and the suggestions. It really helped me process everything last night after that horrible phone call!!

[jenjackson 4]

So the saga continues. I got a call from my surgeon's office and the mistake was 100% on the insurance company's part. My surgeon's office got a confirmation number and everything. Well, it turns out that the insurance company basically told the surgeon's office "too bad". They admitted the mistake but don't want to make it right. So I called the insurance company and the rep said I was supposed to have a call from a manager by the end of the day. I am still waiting on the phone call. Anthem needs to make this right.

I am hoping that they do something to fix the mistake without me having to take further measures. I don't want to have a fight on my hands, but now that the fight has begun, I am determined not to lose.

[1SlimmerMe 122]

@@jenjackson did you ever get a resolution?

[jenjackson 4]

I am still dealing with the insurance company. They are still telling me they are waiting on the original phone call to be pulled that had the conversation with my surgeon's office. I gave a follow up call on Friday after 2 weeks of waiting for a return call. Again I was told they would be looking into it. Getting tired of the run around!

Thank you for checking in on me!

[1SlimmerMe 122]

Until they have said absolutely no, don't give up! I know it can't be easy, but it's worth all your efforts. Hang in there!