Aetna PPO-pissed off!!

JDUB0414 · December 18, 2007

This is my story. The weight loss center sent over what I thought was all my paperwork on 11/19/07 to the insurance company. I received a letter from them on 12/7/07, after calling them regularly for two weeks with regards to the status of my file...stating that they need additional paperwork. I dont know whether or not to be pissed at the nurse at the wieght loss center or at my PCP office. The nurse said she knew exactly how Aetna works and would not send my packet to them unless she had the complete file. I gave them both the print out of what I needed to get approved. Well somewhere along the way our five year weight loss history didn't get sent. I called my PCP on 12/10/07 to ask them to send that info to the weight loss center ASAP and was told they would send it the next day, talked to them 12/15/07 and they still hadn't sent it and was told they would send it on 12/17/07. Talked to them this morning, and they still haven't sent it and would get it out by 12/21/07. Now on the letter I got from the insurance company, said I had 45 days till the date that the file was opened to get them the info or they would make a decision about without the five year history. To me this means they will deny it. My PCP acts as if it's not important enough to rush the letter and it will take a week to get a copy of my medical records. I dont know what to do. I am so upset!!! What should I do?:whoo:

destiny79 · December 18, 2007

the five year weight history OMG that is why I rush my process I don't have a 5 year weight history. I have UHC and was approved in a week my company is switching to Aetna on Jan 1 when I found that out in Oct. I than started pushing to get my surgery done this year with UHC my only requirement was a BMI of 40 and over auto. approved

good luck .(WHY NOT GO TO YOUR PCP OFFICE AND PICK UP THE RECORDS NEED AND FAX THEM OVER YOURSELF)

enjoylife · December 18, 2007

you may be dealing with a pcp that doesn't like the idea of wls. go to the office and stand there and wait for a copy of your records. they won't like it, but you will get what you need. or you could go the long route and switch pcp's. they have to give a copy of your records then. but i would use that as a last resort. just go there and tell them you will wait. then hustle your rear over to a library or your job or whever there is a fax machine and fax it in yourself - or better yet - drive it over and hand deliver it to your surgeon's nurse. on another note, i think a five year history is ridiculous. that's just Aetna's way of avoiding paying for the surgery. heck i wonder how many people age out before they reach the five year mark or how many people just give up. that really sucks and they know it. I'm glad you got yor five years. now remember that most pcp's work more for the insurance companies than they do for their patients. if you want something and you are entitled to it - fight for it. go stand in the office. be polite, but be firm - let them you know will wait - all day if necessary. Good luck to you.

Shell · December 18, 2007

I have Aetna and I just got approved. It was a very, very long haul. I had to stay on top of them. They denied me my first try then my denial was just reversed last week. I now have a tentative date of January 7. I hope things work out for you!!!!

JDUB0414 · December 19, 2007

thanks. I did call them about my records and that's what they said would take a week to get back. I called back and told them, something needs to happen because tomorrow will be 30 days and expressed how ridiculous this was. I received a voicemail today from the nurse stating that the doctor was coming in to type up my husband and I letter and we can pick them up tomorrow. My husband will go to pick them up and stand there until they fax it over to the weight loss center. I will also have him get the copies of our medical records, just in case the insurance company needs something else.

During our six month visits, she seemed as if she was very supportive of the surgery and said she wanted to make sure she provided us with everything they needed. I am hopeful that they will approve us. I will let you all know tomorrow what happens.

JDUB0414 · December 19, 2007

Shell, why did they deny you the first time and how did you get it reversed?

JDUB0414 · December 20, 2007

Well today they finally faxed it to the weight loss center. The nurse at the center has faxed it over to the insurance company today. Hopefully, we'll hear something soon.

destiny79 · December 20, 2007

great finally !!!now I am sending approval vibes your way:eek::omg::clap2:

SpecialK · December 20, 2007

I had a tough experience and was asked to pay $50 administrative cost for my PCP to get the paper records from the past 5 years out of storage since they've gone to computer only in the past 2 years and to give the surgeon's office what Aetna needed on my 5 year weight history, I had to pay the cost for the PCP office to have the paper file pulled from storage, copying done, then sent back to storage.

I should follow up and see if my PCP has completed this after hearing your story. My PCP isn't supportive about weight loss surgery even for those she knows have struggled for years so I'm kind of pushing ahead without her if I have to.

Good luck!

JDUB0414 · December 21, 2007

Thanks Tomecia!! I see you've just had your surgery, how do you feel?

Special K, I would definately stay on them. I think it's ridiculous that you have to pay $50 to get you file. If they went to computer based, they should've been able to get all the info needed to compile a letter for you. I left my last PCP because of ignorant stuff like that and because her staff was so damn rude. I've always had pretty good insurance, so there wasn't a reason for them to be so rude. I know some doctors may treat you based on the type of insurance you have. Ughhh!!!

Anyway, today, I finally got through to the department that makes the actually decisions and the lady called and told me personally that they received the five year history for me and three years for my husband. She said that there is one man that gives the final decision, so I should know soon because he has a deadline before the end of the year. I'm praying that they approve my husband with the info they have.

destiny79 · December 21, 2007

feeling awesome had my post opt appointment today I am down 10.5lbs and I got my bodybugg today. But I just have this feeling that your approval will be coming fast:clap2:

JDUB0414 · December 23, 2007

Tomecia, Thanks, I hope so. I'm glad your feeling great. What's a bodybugg?

I spoke with the insurance company yesterday she said the file will go to the director today, so to check with them on Wednesday because of the holiday.

buffettchick1 · December 23, 2007

I am new to the forum. I have Aetna PPO and have heard nightmares about different insurance companies. Naturally, I have been reading all I can on Aetna and it looks discouraging. I am going to an info forum on the day after Christmas and will be starting the process. Any words of wisdom. I am not good with rejection but have a feeling I will need to get thick skin and fight, fight, fight.... Anyone with helpful hints on getting approved would be really appreciated.

What do they need for the 5 year weight history?:eek:

destiny79 · December 23, 2007

DR. records any kind showing your weight for the last five years, they are trying to make sure you have been a BMI of 35 and over for more than five years.

xenagate · December 23, 2007

My husbands co is switching to Aetna in Jan and I am so happy I had surgery already bc I hear they are horrible. Im nervous abt how they will b bc I need fills still- but anyway- at least I got my surgery before the switch- Im happy. I feel sorry for anyone who has to go thru aetna. But hang in there and keep fighting!!