Insurance and Surgeons Office aren't on the same page!

[mrz.mott 42]

I'm starting to get frustrated! I apologize if I'm not putting this in the right area, but I'm looking for advice. My insurance company told me prior to even meeting with a surgeon that I didn't have a specified length of time to go through the diet and exercise process with a physician. Somehow when the surgeons office called and asked the insurance company for my requirements, they were told a 3 months diet and exercise was required. But when I called them again, I was told no specified amount of time. I get to my third appointment, and I was advised that the insurance required 6 months. What the heck is going on! So I gave them the phone number that I have been calling to verify benefit requirements, and they left a message for my case manager, and she hasn't gotten back to them. So I called my insurance company to see if they could call the surgeons office. Nope! Inbound phone calls only. Ugh! They then told me that it doesn't have to be my case manager that verifies the benefits. So I called the surgeons office once again to tell them to speak with anybody. They are supposed to, and get back in contact with me. I have literally done every other requirement. Why am I getting conflicting information? Why can't we all be on the same page? Am I stepping outside of my boundaries? I feel like I'm bugging everybody about this, but dammit, it's my life/body/time!

I've even contemplated going to a different surgeon. But who knows how much progress I might lose doing that. I just want them to submit it for approval already, I'm getting aggravated!

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[Tricia Renzi Grow 20]

So sorry you are having such a rough time. I hope they get it all straitened out for you.

[KristenLe 5,979]

I got conflicting information too. I hope my surgeon is right and I don't need 6 month supervised diet but I'm not getting my hopes up until auth is approved. Ask for benefits in writing from insurance.

[heidikat72 935]

Ask your insurance company to provide you with your specific plan requirements in writing.

[Read2016 658]

Is it possible this is a surgeon's requirement as opposed to the insurance requirement? My insurance specifically said these are our requirement, your surgeon may have other specific things they want....I think you well within your boundaries to demand a clear answer.

"We can't solve problems by using the same kind of thinking we used when we created them"

Einstein

[mrz.mott 42]

Is it possible this is a surgeon's requirement as opposed to the insurance requirement? My insurance specifically said these are our requirement, your surgeon may have other specific things they want....I think you well within your boundaries to demand a clear answer.

"We can't solve problems by using the same kind of thinking we used when we created them"

Einstein

They said that their requirements would be the same as the insurance requirements. The surgeon even told me that if they verify that there is no specific time frame, they will submit it for approval that day.

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[Read2016 658]

Excellent, now everyone just needs to get on the same page

"We can't solve problems by using the same kind of thinking we used when we created them"

Einstein

[duckydoom 128]

Definitely get your insurance company to send you a copy of the bariatric policy. It should spell out exactly what the requirements are pre-surgery, and then you can take this to your surgeon and compare notes. Either way, you'll know your full coverage benefit and what is expected and required of you.

As others have said, it might just be your surgeon being particular, but it would be good to have everything outlined in writing. Good luck!

[gina171 626]

Some insurance companies won't send you anything in writing....especially if your insurance plan is actually fully-funded by your employer ( your employer actually pays the claims, NOT the insurance company) and they use the " insurance company" for administrative purposes only.

That's how it works with my husband's company. They are a pharma company and they directly set their own health care plan policies and they themselves pay out the claims....they merely use UHC as plan administrators. UHC provides them access to doctors and networks, and UHC manages the plan rules that my husband's company sets....which are sometimes set up differently than UHC rules. So while my insurance card says UHC, it's not really truly UHC.... especially when my company sets up different rules.

But it can be very confusing to deal with at times. Especially when UHC has a blanket policy of 6-month wait, and OUR company plan says BMI and if it's medically necessary are the only requirements.

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Edited June 7, 2016 by gina171

[DNCE 1]

@@mrz.mott

I had a huge issue with my insurance company when I applied for approval, and my surgeon's office genuinely did not know that the insurance company's policy changed. My insurance is funded through my employer, and I have one insurance type for primary care and another for hospitalization. My primary care insurance and hospitalization conflicted on their bariatric policy, and the hospitalization policy ended up controlling with a longer pre-op period.

My hospitalization insurance's policy changed on bariatric surgery recently. I would definitely look up the policy online for your insurance company and call to confirm what the requirements are. On the off chance your surgeon's office is wrong about anything you'll end up getting denied. While I was doing my research on the insurance company and figuring out the requirements I made the appointments a month apart for the 6-month evaluation anyway to cover my bases.

I know this is an extremely frustrating experience to get approval, but hang in there! It's 100% worth it.

[Diana_in_Philly 1,426]

If you are part of a large health plan, most plan documents should be available through the online portal where you can check for in network docs and hospitals or status of claims. I was able to download the bariatric policy for my plan with just one quick search. While my plan does not require any supervised weight loss or anything else, my surgeon (who is part of a Bariatric Center of Excellence) requires three months supervised, three meetings with NUT, starting an exercise program, psych eval., chest x-ray, cardiac clearance, pulmonary clearance, barium swallow/endoscopy and blood work. By the time you get done scheduling all that, you are at 3 months. I started in May. My third visit in July will have everything go out the door to my carrier.

Go on line and see what you can find in the portal. Otherwise, the next time you are in the doctors office, meet with the insurance coordinator and call the ins co and put them on speaker while you are there. Seems like problem solved.

[reachbree 140]

I went through this as well and have many posts and received lots of help from this forum. What ended up happening in my situation is that it all worked out perfectly and I got approved. My surgeons office was just really late getting the updated info from my insurance (BS/CA). This was all after making several calls to the insurance and my Dr.s office.

My surgeons practice is to have patients do 3 months regardless of what insurance requires. SO I did 3 months...really 4 because the first month (assessment) didn't count.

My advice would be to call your insurance again and asked the rep if they can personally contact your surgeons office to inform them. OR get the direct line of the rep and give it to your surgeons office to contact them.

I hate when they aren't up to date on these policies.....

[leliwhoaoh 27]

I'm so sorry that your having an unnecessarily difficult time getting a straight answer. I was fortunate that the answers i got from mu surgeons office, correlated with what my insurance was verbally telling me. Still i took no chances, since my policy info is not available anywhere online, an insurance rep was kind enough to email me the portion of my policy as it pertains to bariatric surgery. That way I am as sure as I can possibly be. The best suggestion i can give you is the same as most everyone, get your policy specifics in writing. And if you have to, call your insurance company while you're in the surgeon's office and have their coordinator speak to someone.

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[Jenjen2016 32]

So, I get on the phone with United Health Care Choice Plus for the third time today, the rep tells me what I see on my benefits page is what they see and what the Dr. Sees, but that is not the case! The insurance told me the same no diet length written in the policy but dr says 6 months! I'm just as frustrated!

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[Read2016 658]

I went to 2 surgeon but I decided to have my surgery with the third... Why? I had 10 months of supervised weight management with an endocrinologist, neither of the first two wanted to hear anything about that. The third surgeon was like if you have the weight management done, we'll fax over the paper to the doc and we can submit for approval.. I was like thank you, your the first doctor listening to me... In so many words he said the other two were just being greedy milking the insurance for office visits because they can... At that moment I knew why I loved this surgeon... He said lets get the paperwork rolling so you can get approved and get sleeved.. All this insurance nonsense is opening the door for greedy people to make extra money.. Some may say it's not all that much extra on one patient but if you think of all the patients they have it adds up... Really their not giving any medical care during the 6 month supervised diet, you don't need to be an MD to weight someone... The place I'm using is a center of excellence and it shows every step of the way... Good luck to you!

"We can't solve problems by using the same kind of thinking we used when we created them"

Einstein