Problem with insurance person

[scharkco 0]

I went to my first seminar Oct 16/08 had first bariatric consultation on Oct 20 - met all the criteria overweight, sleep apnea, hypertension and few other problems - so the question of the 6 month diet history was being tossed back and forth was told by bariatric insurance person that i had to have this was for tricare, called tricare and tricare said they don't have to have this, told bariatric doctor this and he said if tricare doesn't need this than he doesn't. Told bariatric insurance person this so she stated she needed a letter of referral from my pcp and i got that for her. Only visit i had left was with the psyche so the bariatric doctor told me. I had the visit with the psyche, he said everything was good already sent back to bariatric. Called bariatric insurance person and now she is telling me she needs 5 years of medical history. I talked to tricare again and they said that as long as the doctor was recommending me for the surgery i didn't have to have all of this and i told the insurance person this and she said that i am just talking to customer service and she is talking to someone in insurance thats telling her she has to have all of this...

If anyone can give me any advice or feedback, I would greatly appreciate this.

[Tyme2GetRite 0]

First off let me say that it depends on the insurance company as far as what their requirements and guidelines are as far as approval. I CAN ONLY SPEAK FOR MYSELF! i have BC/BS of NewJersey and once i had my consultation with the surgeon they gave me a print out of the requirements. when i got everything together it went to the surgeons office first and they submitted it to the insurance company. i had to have :

5yr history w/ Dr. (just height & weight)

6months w/ Nutrionist

Approval letter from PCP

Psych eval

it can be a mess, make sure you get the names and dates of who you talk to because it seem like someone is not on the same page. you also want to make sure that you do what ever the insurance company wants or they may not approve you :cursing:, UGHHH ! i hated that part. hang in there and don't give up it's worth it !

[gentylwind 1]

I work in this field and she is probably telling you the truth. I know its a hassle, but she is trying to get your surgery approved for you. This requires talking to a different division of your insurance than the front line customer service people, usually an R.N. or higher. They may tell you they don't require it but still tell her she needs to submit it in order to get your surgery approved. Since she is working on your side to get your surgery performed, just jump through the hoops and get her what she needs in terms of your medical records. It should not take more than a phone call and a faxed piece of paper with your signature giving them permission to forward your records on.

It is not at all uncommon for the customer service "front end" people to tell you one thing, but the people in preauthorizations to tell you another.

[gentylwind 1]

It may be helpful to ask her to have a conference call with your insurance with you on the line (a three way call) so you both know exactly what is being said is required.

[scharkco 0]

Thanks so much for your feedback!

[Band_Groupie 3]

Ditto...I'd also suggest you call and ask your insurance for a copy of the actual policy requirements. They can fax them to you or most have them online and they can tell you how to access them. Every insurance company has their requirements spelled out...mine was a little vague on the "comorbidities" as a lot of them are (not an issue for you as you have several of the 'biggies'), but your policy will clearly state how many years or not of history and the same with the diet. I don't have tricare, but mine (BCBS Highmark Western PA) lists the 6 mo. diet but no years of history is listed. Give your Drs. insurance person a copy of your actual policy, then everyone is clear. I've found that even in the same state my BCBS has very different requirements from area to area, and probably even co. to co. depending on what they purchased.

[scharkco 0]

Will do,

Thank you!

[L12 13]

Tricare does NOT require 5 years of weight history. You just need to meet their established requirements; anything else outside of that is a requirement of the doctor, not the insurance.

From the Tricare website (TRICARE.mil Portal):

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
  
• Is 200 percent or more over ideal weight for height and bone structure
  
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)
  

[scharkco 0]

Thanks for the information. I have gotten the same information from tricare and also from the bariatric doctor that he has everything but the insurance person there says she won't submit anything until she has 5 years of medical history and so i guess if the bariatric insurance person has the last say then I guess i will need to try to come up with this medical history....

thanks again everybody!

[haroldrussi 0]

My wife and I are both under TRICARE and hope that we don't end up with any problems getting approved. I have had outstanding support from TRICARE in the past and don't forsee any problems now. Please keep us apprised of your issues/problems with TRICARE so maybe I can get a preemptive strike on them and prevent the slow down of our planned LAPBANDs. We are both hoping to get approved and done ASAP. The only thing I will really miss after the procedure will being able to have a beer every so often. OH WELL, anything to lose the weight. :cursing:

[TQUAD64 9]

Ask for a copy of the insurance requirements in writing. This will greatly assist you in moving through the process.

[scharkco 0]

You mean to tell me no cold one! It was not so much tricare, its the bariatric clinic insurance people, which today now the insurance person tells me even though I'm not doing the six month diet history she will go ahead and submit everything and we'll see what happens.

Good luck to you and your wife!

[TQUAD64 9]

You mean to tell me no cold one! It was not so much tricare, its the bariatric clinic insurance people, which today now the insurance person tells me even though I'm not doing the six month diet history she will go ahead and submit everything and we'll see what happens.

Good luck and let us know what happens. :whatchutalkingabout

[scharkco 0]

You mean to tell me no cold one! It was not so much tricare, its the bariatric clinic insurance people, which today now the insurance person tells me even though I'm not doing the six month diet history she will go ahead and submit everything and we'll see what happens.

Good luck to you and your wife!

Will keep everybody posted, thanks for everyone support!