Information to help me with a second level appeal

[CheriB78 4]

I have 2 insurance companies, WebTpa (had to have approval from Active Health which does medical determination for the procedure and BC/BS federal. I had a lap band in 2008 which did not work very well. I was having a band removal and RNY (which I actually had last week on the 9th of February). Active health approved my band removal but denied my RNY because I did not lose the required 5 percent of weight, which my surgeon said not too, I would be too close to the 35 BMI level. BC/BS approved everything ( they paid for the band in 2008) but are out of network. I would like expert advise if I should try the 2nd level of appeal and with what information? Or just let it go and pay the bill that is left. The thing that really gripes me, is I had been with company for 18 years and a director that had been recently hired got approval in a few months and was not required to lose weight or go through the 6 months of diet, exercise, etc. I have since resigned and am starting a new job next week and am not sure to proceed with the appeal and insurance commissioner or just let it go. Any advise would be appreciated. Thanks in advance Cheri

[James Marusek 5,244]

Disputing health insurance companies is a little bit like talking to a brick wall. Even when the words are in black and white in the policy, they deny claims. But if you have the time and patience and want to give it a go, then by all means try.

It sounds like you have 2 disputes. One is with Active Health. They required that you lose 5% of your weight before you qualify. But you failed to do this (with the consent of your surgeon). The reason you gave is that you would fall below the 35 BMI requirement. Many insurance companies require that you try and lose weight and that your qualification to the BMI requirement is determined at the initial weight officailly taken when you first apply for the surgery. So if you had lost the 5% of your weight you might not have been penalized for it. The area that I would explore is why your surgeon did not push you to lose weight during the pre-op period. Was there some medical issues that would make this weight loss a problem. If so can you surgeon's office articulate this in a letter to your insurance.

The second dispute might be with BC/BS, that appears to be out of network. The cost incurred generally includes the hospital, the anesthesiologist, the surgeon, and a secondary surgeon. It is difficult to ensure that all of these are within network before surgery. Maybe impossible. I believe BC/BS offers fairly good policies and I suspect that most hospitals are within network. So anyways I would check to see what is in network and out of network for each of these elements. This is probably accessible over the internet.

During my second round of pre-op testing, one of my specialist clearly showed up as being in network (that is why I chose him) but when I received the bill I was charged as an out of network. His name was clearly listed on the latest in-network doctors. When I talked to the insurance they claimed he was out of network. I told them that their website clearly showed him as in-network. But they still disputed the charges. I met with the specialist staff, they said the specialist was in-network and that they would handle it. And they did. I never received that bill.

Also even though I made sure that my hospital, surgeon, anesthesologist were all in network prior to the operation. I received a large bill for the assistant surgeon. I didn't even know there would be an assistant surgeon. It turns out that this assistant had not yet submitted the paperwork for becoming qualified for in network. I asked the surgeons office to reconsider and they said they would take care of it. Again, this charge disappeared.

So I had better luck working the problems out with the surgeons, hospital and other doctors than with the insurance companies.

[CheriB78 4]

Thanks James, I am leaning to just let it go and continue to get healthy. I appreciate all your help and info.