I'm Getting the Insurance Runaround... Need Help!

[LDNurse 0]

Hi. This is my first post, but I've been lurking around in here for a while. I finally got banded 1/9/08. I had to do two 6 month diets, because the ins co. did not like my doctors documentation on the first diet. They told me I needed to do another diet, and then they could approve me.

I went to another dr, my pcp, and redid a whole more 6 months. And guess what? Thery turned me down again. They didn't like my drs documentation. I went back to my pcp, crying. She wrote her notes over again and I resent it to the ins co. Then they said we need a weight from 2003. I had given them weights for 11/2002 and 1/2004, but not 2003. Well I finally found one and sent that. The moral of this rather long and rambling story is: THEY DON'T WANT TO APPROVE YOU. IT COSTS TOO MUCH MONEY. But don't give up. I finally got approved. Maybe they were just tired of me. Whatever--it worked

Good luck and if you have to do 6 mo diet--it goes by really quick!!

[destined2befree 0]

yeah, why not tell us who u really are? yeah, you just want to help.....yourself to other people's money!!!! you aren't being open and honest and feel you are being decietful to people seeking help in finding a skilled professional....unfortunately there all a lot of people like you preying on desperate people. It is good that people know who you are and the word is getting around about you...please refrain from posting on here since you are not a patient. IF people want your help, they'll come looking for you! go away now!

[coltonwade 27]

Hi. This is my first post, but I've been lurking around in here for a while. I finally got banded 1/9/08. I had to do two 6 month diets, because the ins co. did not like my doctors documentation on the first diet. They told me I needed to do another diet, and then they could approve me.

I went to another dr, my pcp, and redid a whole more 6 months. And guess what? Thery turned me down again. They didn't like my drs documentation. I went back to my pcp, crying. She wrote her notes over again and I resent it to the ins co. Then they said we need a weight from 2003. I had given them weights for 11/2002 and 1/2004, but not 2003. Well I finally found one and sent that. The moral of this rather long and rambling story is: THEY DON'T WANT TO APPROVE YOU. IT COSTS TOO MUCH MONEY. But don't give up. I finally got approved. Maybe they were just tired of me. Whatever--it worked

Good luck and if you have to do 6 mo diet--it goes by really quick!!

I do have to agree with you LD.

I tried to get insurance ( Private insurance) AFTER my band. I was turned down previously because i was TOO FAT, right now im on the Texas High Risk Health Plan . I am a PERMANENT DECLINE since i Have the Lap Band for Private Health Insurance. Until they change the laws, minds about the band.

its CRAP the insurance companies can do what ever the hell they feel like even when YOU are paying the premiums

Mindy

[010308 0]

Maybe a new thread could be set up warning that there are people on this site trying to drum up business so if you see something just be aware of that.

As for the insurance run-around. I still don't believe most insurance carriers are trying to get out of paying for a surgery that is a contract benefit, but they have guidelines that they have established that they are following.

Personally I think the problem is related to a disconnect between Customer Service-who relay's information to the members, and Medical Review who establishes the guidelines and is responsible for following those guidelines when they review cases.

So here are some suggestions to go into checking on coverage with your eyes open:

• Know what your contract says-is obesity treatment and WLS a covered benefit? You should be able to find this information in your contract benefit booklet. When I'm asked I tell people to check the exclusions section first. If you do not see obesity treatment specifically listed as an exclusion then there is a good chance that it is covered. Next check the surgery section to see if you can find anything out.
  
• If you do not have a benefit booklet or after reviewing your benefit booklet you believe that WLS is covered then check with Customer Service to verify coverage, if pre-auth is required, and if so what is needed for pre-auth approval.
  
• Make sure you note the date and time of your phone call and the name of the person you're talking to (first name, last initial). They may also be able to provide you with a tracking number that is a reference to your phone call with them.
  
• If you find out WLS (in this case lap-band) is a covered benefit then you might consider checking on-line at your insurance carriers web site to see if they actually have their pre-auth criteria posted.
  
• My last suggestion is that if you are told you need to submit a pre-auth then you should make them tell you EXACTLY what they want. Don't just accept, "We need proof of a 6 month medically supervised diet where you either lost weight or didn't gain weight." If they tell you this say, "Who can supervise this program? My pcp, specialist, dietician? What information will I have to provide to prove that I have been on a medically supervised program?" Etc.
  
• If you get the impression that the Customer Service Rep that you're speaking to is wish-washy, not confident that s/he knows what s/he's talking about (hints to this would be putting you on hold while they check this out, saying they have to check with someone else, lack of confidence in their tone of voice) ask for this information to be sent to you IN WRITING!

[WASaBubbleButt 41]

Maybe a new thread could be set up warning that there are people on this site trying to drum up business so if you see something just be aware of that.

Already done. See my sig link, post #3. ;o)

[Ellisa 6]

Did the original poster lose interest?