Surgery approved and done now insurance trying to deny claim

[ladyblueeyes 0]

I have Humana. I am self insured. My surgery was approved after meeting all the qualifications BIM over 40, Psych exam, Dietitian and a 6 mo Dr. supervised diet. All of which took almost a year. I had my surgery performed on 9/15/08. Now the surgery has still not been paid for. About 5 days after surgery I was sent a letter that stated that due to a diagnosis code that was used. My medical history for the past 5 years was needed to validate the claim. In short after many many phone calls later. It comes down to the fact that I gained 50 lbs from the time I had originally taken out the insurance and the time the surgery was done. My BMI was lower when I took out the insurance as I am a yo yo dieter and as most can lose the weight for the short term but can not keep it off. They are now trying to deny the claim. The thing is if they had denied the surgery for that reason before it was done I could have understood that. But my weight from the start to end was no secret. They had all the info and all the records from my Dr. supervised diet to see what I had gained. So why now after a $28,000.00 bill would they try to deny it. If they wouldn't have approved the surgery in the first place I would not have had it done. As there is no way I can afford it. That is why I jumped thru hoops for so long to get it approved. I am so upset!!! Can they do this ? How can I fight this ? I could lose everything if they refuse to pay. I live paycheck to paycheck now and could lose my home if they start garnishing my wages. Any info would be much appreciated. Thanks and sorry so long :yikes:

[ccarter8219 0]

I have Humana. I am self insured. My surgery was approved after meeting all the qualifications BIM over 40, Psych exam, Dietitian and a 6 mo Dr. supervised diet. All of which took almost a year. I had my surgery performed on 9/15/08. Now the surgery has still not been paid for. About 5 days after surgery I was sent a letter that stated that due to a diagnosis code that was used. My medical history for the past 5 years was needed to validate the claim. In short after many many phone calls later. It comes down to the fact that I gained 50 lbs from the time I had originally taken out the insurance and the time the surgery was done. My BMI was lower when I took out the insurance as I am a yo yo dieter and as most can lose the weight for the short term but can not keep it off. They are now trying to deny the claim. The thing is if they had denied the surgery for that reason before it was done I could have understood that. But my weight from the start to end was no secret. They had all the info and all the records from my Dr. supervised diet to see what I had gained. So why now after a $28,000.00 bill would they try to deny it. If they wouldn't have approved the surgery in the first place I would not have had it done. As there is no way I can afford it. That is why I jumped thru hoops for so long to get it approved. I am so upset!!! Can they do this ? How can I fight this ? I could lose everything if they refuse to pay. I live paycheck to paycheck now and could lose my home if they start garnishing my wages. Any info would be much appreciated. Thanks and sorry so long :yikes:

Did they give you an approval letter prior to the surgery? If they did, they should honor the approval letter.

Crystal

[ladyblueeyes 0]

Yep I have the approval letter so does my surgeons office.

[HeatherO 7]

I dont think they can do much now since you were already approved with the information they had on file.

What was your final BMI when you got the insurance and what was the BMI at surgery? Did you have any comorbidities?

[RestlessMonkey 7]

I agree with Jack...call your state's insurance commission. Pronto. Don't let it go on. Also check your credit to make sure they don't mess it up.

[TQUAD64 9]

Yep I have the approval letter so does my surgeons office.

I don't see how they can go back on their approval letter. Thank goodness you have that letter. You cannot be held responisble for their mistake.

[gingerbug 3]

This could be as easy as your doc office resubmitting the claim with the correct code. Call the billing office and ask them

[ladyblueeyes 0]

I dont think they can do much now since you were already approved with the information they had on file.

What was your final BMI when you got the insurance and what was the BMI at surgery? Did you have any comorbidities?

Im not sure what my BMI was but I was around 200 to 215 at the time I took out the insurance. I had been doing the Atkins diet and kept the weight off for about 6 mo then as soon as I started introducing carbs in to my diet I totally fell off the diet wagon and the weight came back on very fast. When my surgery was aproved my BMI was 40.1 I did not have any comorbidities.

Edited January 17, 2009 by ladyblueeyes

[ladyblueeyes 0]

This could be as easy as your doc office resubmitting the claim with the correct code. Call the billing office and ask them

I guess I should have added in my post that the diagnosis code that caused the the insurance to start this so called investigation was the code used for obesity. I was floored when they told me this. I told them I had the surgery because I was obese that's why the surgery is call weight loss surgery. Of course I would be diagnosed obese. They even have a bariatric team that I was in touch with several times during the pre approval process. I called them many times to make sure I was following all the steps properly because I did not want to be denied and have to appeal. I guess that's what makes this so crazy. I called them today to see what was going on and was informed that they now have all my medical records and my case is now being looked at by underwriting. They said it may take up to 5 more weeks to review my records and make a decision to pay or deny. They said I'll receive a letter with the decision but they can not give me any further info over the phone. And if I am denied I will need to sign a attached paper and send it back to them then after they receive it I can call in and then someone will help me with my appeal.

[laurie39 0]

That's for the privacy issues. They should be able to verify who you are by asking for your name, dob, & your ss#. I have worked in insurance for 10 years and have never told an insured to sign a form and return it so we can talk to you over the phone. Read very carefully the letter they send to you. You do need to contact your insurance commission. The insurance company can eat $28,000 if they weren't supposed to approve the surgery and did anyway. I honestly don't believe the surgeon would have done the surgery if it hadn't been approved.

My moms claim for her annual pap was denied by medicare because it was for birth control. She laughed, I'm 64 years old!! It could be as simple as one # being wrong.