Fighting the Insurance/PCP Blues--Help!

[2nd chance 0]

HI Everyone,

I am really really struggling...I am seriously having the fight the insurance co & my PCP blues. Pasted below is draft copy of a letter that I am working on to send to the insurance co. and maybe even the insurance consumer division.

Although a really tight squeeze for now, I am working on Plan B. Dr. Alvarez in Mexico, 9750 for sleeve.

Here struggling...having gained 18 pounds since September 15--all of my clothes are fitting way way way toooooo tightly! Bumming

Here's my letter! I just dont know what to do.... Any insight is greatly appreciated!

I am not sure if I should be outright saying I want to request an appeal or just asking for an update. Please review and give me your insight. Thanks!

Group/ID Number: XOH842901948/H06800

Primary Care Physician: Dr. Derek Kelly

Diagnosis: 278.01 Morbid Obesity

Procedure: 99241 Office Consultation

Referred For: Office Consultation

Requested: 12/9/08 Denied: 12/9/08

Services Requested: Consult with Dr. Vitello for a Sleeve Gastrectomy

Referral Authorization No. 23,562—Denied (Referral Denied—This is a request for an out of network non-contracted provider with Managed Health Care Associates

Managed Health Care Associates

2740 W. Foster Avenue, Suite 411

Chicago, Il 60625

FAX: 773-271-0264

Illinois Department of Insurance Consumer Division

100 W. Randolph Street

Suite 15-100

Chicago, IL 60601

Greetings

I a writing to formally request an updated status of the referral decision rendered in December 2008.

First of all, the services requested are inaccurate. Since October 2007, Dr. Derek Kelly has provided referral authorizations for me to see Dr. Vitello regarding lapband adjustment. From October 2007 until September 2008, I visited Dr. Vitello for lapband adjustments and presented with complications of my adjustments on a monthly basis. Resultingly, September 2008, I had to have emergency surgery to remove my lapband due to slippage. I followed up with post-operative care with Dr. Vitello, who then consulted with me regarding revisional bariatric surgery. In the interim, I informed Maria, of Dr. Kelly’s office and contacted the BCBS of IL to be advised of my benefits coverage and protocol for seeking revisional surgery. At that time, I was advised of the criteria for coverage, which I meet now and did so at the time of request, and advised Maria of the same. She advised me to have Dr. Vitello submit the referral authorization and that she would handle the request, as she had handed the processing of all of my prior referral authorizations to Dr. Vitello.

Upon mutual interest, Dr. Vitello petitioned for referral authorization for revisional bariatric surgery, vertical sleeve gastrectomy. My last follow up appointment with Dr. Vitello was October 31 and the referral authorization was submitted twice by Dr. Vitello’s staff (University of Illinois at Chicago) before warranting a response by the Managed Care Group. This petition submitted in full disclosure, my operative and post-operative reports and medical necessity substantiating the need for the procedure. According to my insurance terms, bariatric surgery is a covered benefit as long as it is deemed medically necessary; this is furthered for revisional bariatric surgery with indication that as long as the first bariatric surgery was medically necessary, there is no waiting period for clearance for the authorization of a revisional surgery. Additionally, according to my policy’s terms and conditions, I have been advised of the following:

Repeat of a covered bariatric surgery may be eligible for coverage only when ALL of the following criteria are met:

• For the original procedure, patient met all of the screening criteria, including BMI requirements
  
• The patient has been compliant with a prescribed nutritional and exercise program following the original surgery
  
• Significant complications or technical failure (i.e., slippage, etc.) of the bariatric surgery has occurred that required take down or revision of the original procedure that could only be addressed surgically
  
• Patient is requesting reinstitution of an acceptable bariatric surgical modality.
  

Dr. Vitello submitted his referral authorization to Dr. Derek Kelly indicating my request to reinstitute an acceptable bariatric surgical modality, vertical sleeve gastrectomy. On December 9, I received paperwork advising of a decision of denial for a consultation. It indicated the denial was based on the fact that the services are available in-network and the request was from a non-contracted provider. The basis of this claim request for out-of-network coverage is due to this surgical procedure being revisional bariatric surgery, which is an acceptable bariatric surgical modality.

Secondly, the letter advised of an alternative for the non-approved service, to contact Dr. Kelly for a referral to an in-network specialist. On December 15, 2008, I met with Dr. Kelly in follow-up to the denial. Dr. Kelly advised that he needed to submit supplemental supportive documentation along with the referral for processing to secure an affirmative decision. Dr. Kelly then proceeded to review my operative report records from the surgery and reviewed my other health records in my medical file and interviewed me regarding my health status. Dr. Kelly indicated this procedure should take approximately 30 days maximum and to anticipate an affirmative response to proceed with revisional bariatric surgery and that I had his medical support in substantiating the medical need.

I have been waiting since December 15, 2008 and to date am more frustrated now than ever. For the past 2.5 months, I have meticulously called Dr. Kelly’s office regarding a status update. Maria, the administrative assistant, has provided several updates. The updates have included the fact that the previous medical director retired and was replaced and the new director was then on vacation, to the medical director making request for additional paperwork (which was submitted), to the medical director needing to meet with Dr. Kelly regarding the details of the approval process for this type of referral authorization, to the medical director and Dr. Kelly being unable to meet to further discuss the nature of my referral, to Brenda communicating that there was never a properly submitted referral from Dr. Kelley to the Managed Care group which resulted in the initial denial decision. In my first direct contact with Brenda Blazek, the Referral Coordinator who signed the referral denial letter, she claimed to know nothing regarding my case and further indicated that there was no documentation in my file. When I followed up with Maria with Dr. Kelley’s office, she advised that Brenda did not find any information in my file because all of the information was being held by the medical director. Whatever the real case is, this is neither professional nor acceptable in accordance to my patient’s rights under section 502(a) of ERISA. Just yesterday, I called and spoke with Maria five times to get an updated status, to exhaustedly be declined, yet promised an update by the end of the work day. I have not spoken with Maria, nor have I missed an update call from Maria. This has been my experience for the last 2.5 months.

Below is an excerpt of the fax sent to Dr. Kelly, which was confirmed as received by Maria on February 5, 2009.

Maria,

I would like to reiterate that on 12/9 the referral authorization stated that the procedure, Vertical Sleeve Gastrectomy, is a covered benefit in-network; however my request was to have the procedure done by an out of network provider. Additionally, this was confirmed by Tammy on yesterday at 12:50 with Blue Cross Blue Shield that this is a covered medical benefit as long as it is deemed medically necessary.

My appointment with Dr. Kelly in December was to have provided me with a specialist referral to have the procedure done or we could have executed an appeal. I think Dr. Kelly submitted an appeal for coverage of the procedure; however, I am requesting to have this surgical procedure done by Dr. Vitello or be advised of the in-network provider who can perform this surgical procedure.

Even in accordance to the appeals process, the timeline has been elongated to address issue of medically necessity when that is not the matter—the issue is approval for out-of network coverage or referral to an in-network specialist.

I hope this clarifies the situation more.

I will call you tomorrow to see if you have an updated response.

Additionally, I was contacted by the non-contracted provider’s office as a follow-up to the request in January and February. Last week, I advised them of the insurance referral hassle that I have been experiencing and they formally resubmitted their request, directly to Dr. Kelly (attention Maria), to the medical director of the Managed Care Group and to Brenda Blazek. To date, no response has been received; however, they have confirmed receipt of such documentation.

Resultingly, I am assuming that since the only official documentation I have received to date is the referral denial, then I am evoking my patient right to request an appeal, specifically an expedited appeal process. However, I am highly dismayed because Dr. Kelly advised that there would be no need to execute an appeal. I would like to seek clarity first on the status and if this is in order, I would like to request an activation of the appeals process and under separate cover I will or will have my attorney to handle the appeals process. Before escalating to that level, I am very much interest in seeking resolve immediately.

If and when I need to activate an appeal, I am requesting an expedited appeal process because my health at this point is continually declining and it is therefore imminent and serves my best interest to not further jeopardize my quality of life by waiting for a decision.

Since December, the following symptoms I have presented:

• my breathing has become labored and therefore results in extreme shortness of breath
  
• my severe obstructive sleep apnea condition has worsened (hypopnea with severe oxygen desaturation)
  
• my acid reflux has returned
  
• my amenorrhea has returned
  
• and I have again began experiencing tumultuous joint, knee and lower back pains