Doctors office insisting on requirements my insurance company does not need

[LacyMay 1]

Hello everyone!

I'm in the process of starting this journey, having done all kinds of research before making my first appointment. At my appointment yesterday I was given standard requirements needed by my insurance company, such as 6 months of a doctor supervised weight loss program and 3 years of weights showing a BMI over 40. I told them that this wasn't required by my particular insurance policy, but they really didn't believe me and said until I had proof of that these were my requirements. I called my insurance company again to verify that all I needed was a current BMI greater than 40, and 5 days notice before the procedure was done. I called the doctor's office to let them know this, and that my insurance company said they could call the provider number on the back of my card to verify. For some reason this office does not want to call the provider number, just telling me to forward them the exact policy when I receive it. That's fine, I'll send it to them when I get it, but when asking the doctor's office a question today I was told that even if the insurance company does not require 3 years of weights they will not submit for approval unless they have 3 years of weights. I asked why in the world they won't submit for approval without it when the insurance doesn't require it, and the doctor doesn't require it. I again suggested they call the provider number and they still will not call it, just wanting it in writing because 'in all our years doing this and dealing with numerous insurance companies we have never had one not require the 3 years of weights'. Now, this is supposedly a very good surgeon that does nothing but these types of procedures. Is this normal that they will not call the provider number to get the details on my particular policy so they can stop giving me inaccurate information? Has anyone else experienced this or something like this before?

[Sosewsue61 3,185]

Do you have a primary care provider that can just give them the 3 years proof? That part would be easy to just do.

Does your insurance co have an online portal where you can log in, email your policy to the doctor's office? I would ask for the email of the insurance coordinator at the dr's office and email it to them. Done.

Then I would write a letter to whomever is the business manager of the medical group and just include the facts of your issues without accusations on the staff, and ask questions - ' is there another reason this is standard procedure that I am not understanding or aware of?' ,etc.

Be polite and just include the facts.

Good luck.

I was personally glad to have these months to evaluate where my head is regarding food and habits.

[LacyMay 1]

I haven't had a BMI over 40 for the past 3 years, more like 38, so I really don't want to give that information to the insurance company if they don't need it, just in case it makes them decide to use it as a reason to not approve. Unfortunately, it was the manager I spoke to last. My insurance company is emailing me the information, which I will forward to the office when I receive it. I just hadn't heard of anyone having a problem where the INSURANCE company has to advocate to the DOCTOR instead of vice versa, which it may have to come down to it seems lol. I've been doing my research and preparing myself for months already, I just hadn't made the initial appointment before now because I wanted to be sure to have my out of pocket expenses on hand, and it's tricky to be able to schedule something like this around my husband's work schedule. After reading so many experiences on this forum and others I had just thought the doctor's office would be the one contacting my insurance to find out what is needed. I loved the surgeon when I met with him, I'm just not very impressed with the office staff so far. I guess I just needed to vent, and wondered if it was normal that they wouldn't want to call to find out specific's on my particular policy. My insurance company doesn't understand why they aren't calling the provider number either.

Thank you for the good wishes!

[Introversion 1,876]

3 minutes ago, LacyMay said:

I haven't had a BMI over 40 for the past 3 years, more like 38, so I really don't want to give that information to the insurance company if they don't need it, just in case it makes them decide to use it as a reason to not approve.

Same here...due to yo-yo dieting, I had a normal BMI of 24 in October 2013. By October 2014, my BMI was up to 37 (rapid regain after a diet) and I qualified for bariatric surgery.

Thank goodness my insurance company didn't demand proof of my previous weights over the years.

[LacyMay 1]

I was celebrating hard when I found d out I didn't have to jump through any crazy hoops for the insurance company! Then the crazy office wants me to jump hoops anyway lol

[ColleenErin1974 195]

Hello! My insurance only required a 3 month medically supervised diet. I didn't have to get prior approval, but my surgeon required quite a few tests and lab work. Those were for getting medical and psychological clearance for the surgery. To make sure it was safe for me.
Good luck on your journey!

[LacyMay 1]

11 minutes ago, Introversion said:

Same here...due to yo-yo dieting, I had a normal BMI of 24 in October 2013. By October 2014, my BMI was up to 37 (rapid regain after a diet) and I qualified for bariatric surgery.

Thank goodness my insurance company didn't demand proof of my previous weights over the years.

I was celebrating hard when I found d out I didn't have to jump through any crazy hoops for the insurance company! Then the crazy office wants me to jump hoops anyway lol

[LacyMay 1]

7 minutes ago, ColleenErin1974 said:

Hello! My insurance only required a 3 month medically supervised diet. I didn't have to get prior approval, but my surgeon required quite a few tests and lab work. Those were for getting medical and psychological clearance for the surgery. To make sure it was safe for me.
Good luck on your journey!

Thank you for the good wishes!

I don't mind doing the things that are required by either the surgeon or insurance company. I just took issue with them saying that they would not even submit for approval without the 3 years weights when the insurance doesn't want it, nor the doctor. The insurance company said 'Why would they not at least submit for approval if we don't need it? All that could happen is it would be approved or denied?"

[JT2002TJ 170]

The first time the Surgeon's office said they wouldn't make a call to my insurance company, would be the last time they got a cent of my money.

It is normal for Surgeons to have additional requirements to make sure the surgery goes smooth, but weight history is typically not one of them. Most surgeons I know are against the hoops to do with weight the insurance companies require (3 months, 6 months, years...). They would like to make the decision about patient's weights themselves (they as in the medical team, hospital, surgeon, anesthesiologist,...).

Remember, they are a business, this is an elective process, where their business is by patients choosing to visit them. They are about to make $25k+ from you (copayments + insurance payments).

I suggest going somewhere else. I'm not sure where you live, but if it is near a big city, bariatric surgery groups are everywhere.

[RSM 69]

I agree with the above post from JT2002TJ

[LacyMay 1]

1 hour ago, JT2002TJ said:

The first time the Surgeon's office said they wouldn't make a call to my insurance company, would be the last time they got a cent of my money.

It is normal for Surgeons to have additional requirements to make sure the surgery goes smooth, but weight history is typically not one of them. Most surgeons I know are against the hoops to do with weight the insurance companies require (3 months, 6 months, years...). They would like to make the decision about patient's weights themselves (they as in the medical team, hospital, surgeon, anesthesiologist,...).

Remember, they are a business, this is an elective process, where their business is by patients choosing to visit them. They are about to make $25k+ from you (copayments + insurance payments).

I suggest going somewhere else. I'm not sure where you live, but if it is near a big city, bariatric surgery groups are everywhere.

I agree with you. I've been thinking about it and can't think of any excuse I can come up with for why they wouldn't make that phone call. As much as I like the doctor, the office staff is who I will be dealing with most and if I have to tell them how to do their job it should be a huge red flag. Thanks for your input!

[JT2002TJ 170]

13 minutes ago, LacyMay said:

I agree with you. I've been thinking about it and can't think of any excuse I can come up with for why they wouldn't make that phone call. As much as I like the doctor, the office staff is who I will be dealing with most and if I have to tell them how to do their job it should be a huge red flag. Thanks for your input!

Yeah, doesn't make sense. And even if you talk to the surgeon about the office staff (basically go around the staff), it will just create tension.

I would suggest calling and speaking with the office manager, after you found a new surgical group, and explain why you left the group. Hopefully this will help someone else in the future.

[Callisto 79]

Right, I agree 100% if they are not going to advocate for you prior to surgery then how are they are going to advocate for you during and after surgery? It might be a sign of things to come - just more of the same, if you don't change surgeons.

Of course, you might let the surgeon himself know why you left. Sometimes the surgeon does not realize that his office is being less than proactive in your surgery.

I had to have two years of weight history. I was denied two years ago because the year before that my BMI dropped below 35 as I was on diet pills. I just could not keep taking those pills and so I gained it back. I was so disappointed. This time, two years later, I went through the entire process again of all the NUT appointments, paying for the psych and was approved.

Yeah, I hope you are able to find another surgeon in your area that you trust. Good luck!

[JT2002TJ 170]

2 minutes ago, c1ndy said:

Of course, you might let the surgeon himself know why you left. Sometimes the surgeon does not realize that his office is being less than proactive in your surgery.

I was going to suggest the above, but in my experience we don't get to see the surgeon without a paid visit. Even with a paid visit, you have to have a good reason as their schedules are booked up. For me, I saw my surgeon during the initial group seminar and the next time was during the initial office visit (where my insurance requirements, the surgical group requirements were provided, and a conversation to decide which WLS was best for me). I have my final structured (sixth) diet weigh in tomorrow (8/25/2017) and I will not see the surgeon until right before the surgery after my final insurance approval (this will be the second one-on-one meeting with my surgeon).

I have had a stellar experience with my group, including email responses from my nurse coordinator within 24 hours (often within an hour).

If you have a patient portal, sometimes you can reach the surgeon this way, but even this way it is often routed through the office/clinical staff and may not actually reach the surgeon.

[Callisto 79]

Just now, JT2002TJ said:

I was going to suggest the above, but in my experience we don't get to see the surgeon without a paid visit. Even with a paid visit, you have to have a good reason as their schedules are booked up. For me, I saw my surgeon during the initial group seminar and the next time was during the initial office visit (where my insurance requirements, the surgical group requirements were provided, and a conversation to decide which WLS was best for me). I have my final structured (sixth) diet weigh in tomorrow (8/25/2017) and I will not see the surgeon until right before the surgery after my final insurance approval (this will be the second one-on-one meeting with my surgeon).

I have had a stellar experience with my group, including email responses from my nurse coordinator within 24 hours (often within an hour).

If you have a patient portal, sometimes you can reach the surgeon this way, but even this way it is often routed through the office/clinical staff and may not actually reach the surgeon.

You are right, we don't get to see them that often. If you wrote a letter it might get to the business office anyway. The patient portal would be a good idea if it is available. I am not usually a confrontational person but I had it out with the office manager of a chain dental company. It was about insurance. I was fighting insurance (long story) and she made a snide comment about my step-daughter, very unprofessional. She said that insurance was not going to cover it and that my daughter's teeth must not be that important if we weren't able to pay for it. In that case I wrote a letter to the corporate office. Then I received a huge apology. Insurance ended up covering $10,000 worth of work as my step daughter had slipped on a cement culvert at the pond and busted out her front teeth, awful experience. That poor girl. However, with wls doctor's they are not going to have a "corporate" office. It had nothing to do with the dentist, he was awesome, but it was the office manager that ticked me off. In this case her surgeon is probably great but she is dealing with the office also.

I am glad to hear you have had such a great experience. How exciting that you are so close to approval.

My group has been awesome. I have even texted with my coordinator because I am on the go a lot and some days have back to back clients it is difficult for me to find time to talk on the phone and it helped that we could text back and forth. My coordinator makes me feel comfortable and I can ask her anything.