Insurance Requirement Question

[ashleey921 62]

Maybe someone on here can help me because everytime I call Humana for an answer I get a different one. So the requirements are changing for surgery effective May 1,2017, to me this means that I would need to complete each of these requirements within 6 months before my surgery. What do u all think?

Clinical record* of participation in and compliance with a multidisciplinary surgical preparatory regimen (within 6 months prior to surgery) which includes the following:

o Absence of weight gain during the course of the program; AND

Behavior modification regarding dietary intake and physical activity (unless medically contraindicated); AND
o Nutrition education/counseling with a dietician or nutritionist that addresses pre- and postoperative dietary intake expectations; AND

• Preoperative psychological evaluation and clearance (within 12 months prior to procedure) to rule out psychiatric disorders (eg, chemical dependency, major depression or schizophrenia), inability to provide informed consent or inability to comply with pre- and postoperative regimens

*Clinical record documentation must include a summary of historical (failed attempts) as well as details of present exercise program participation (eg, physical activity, workout plan), nutrition program (eg, calorie intake, meal plan, diet followed), BMI and/or weight.

So, if I started this journey in January 2017 but dont want to have my surgery until maybe July-August would I submit everything now before May 1 before these changes take effect? I kno I should be asking my insurance company but nobody seems to know and I havent got the same answer twice after calling for clarification atleast 5 times. So now I want to know what you all think, do I sound like Im right or no?

[MSinger 348]

Please don't take what I say as bible truth, but I review surgeries for a major insurer (not Humana). For my company, if there any policy changes, they would go into effect from the day the new policy was published. Up until that day, the old policy will apply. The issue of a request being submitted shortly before a change in policy is something we have never explicitly been told how to handle. In the end, it may be up to the insurer.

I'd say, if you have all criteria met now for the current policy, then submit now. An approval cannot be "taken back" once it's been issued. My company issues approvals that are good for one year for the line of business I handle. Some lines of business have 6 month approvals. And of course, it may be different for other companies. In any case, My suggestion is if you meet criteria and are denied for the basis that you don't meet criteria for the future policy, then appeal that decision. It is almost always worth it to appeal a denial since I see so many denial decisions overturned. The only hard stop I know of is if a group does not cover bariatric surgery. Other than that, it's always worth pursuing.

Hope this helps.

[ashleey921 62]

It does. Thank u so much for replying!

[Sosewsue61 3,185]

I have Humana - Illinois HMOx. I received the same info that you did. Don't call, log in online and use the communication tool and ask questions there, that way you have a written record.

I asked specific questions and requested specific answers - how many preop visits required, how long is the medically supervised diet required to be, what type of exercise log/program is required, etc. The reply was that the duration and program was up to the physicians/surgeon.

They answered me within 2 days each time I submitted. Print these out (keep a copy for your records) and take to the surgeon's office and give them to whoever handles the insurance submissions.

Keep in touch.

[ashleey921 62]

I have Humana - Illinois HMOx. I received the same info that you did. Don't call, log in online and use the communication tool and ask questions there, that way you have a written record.
I asked specific questions and requested specific answers - how many preop visits required, how long is the medically supervised diet required to be, what type of exercise log/program is required, etc. The reply was that the duration and program was up to the physicians/surgeon.
They answered me within 2 days each time I submitted. Print these out (keep a copy for your records) and take to the surgeon's office and give them to whoever handles the insurance submissions.
Keep in touch.

That's a great idea. Thanks!