Contingent Denial Pending "Peer Conference"

[Violetflame 0]

Please forgive new thread-but i have been all over this place for hours. WHA THE??? Just spoke w/ins and the rep said it wasn't flatly denied. A conference call w/my dr is requested within ten days. Also there are appeal options. Has this happened to anyone else? :thumbup::mad:One would think that the CEO's enjoy large enough bonus's that the ensured could use a covered benefit when medically necessary and not have to have your surgeon plead your case during a conference call-how demeaning for them. No small wonder dr's are abrupt, our insurance companies are telling them how, when and on whom to practice!!! Infuriating!! I pay for insurance!! Legal theft! Should be in jail!! GAME OVER.

[Violetflame 0]

Mac, Elisabethsew, Oregondaisey, Wasa!!! WHERE is everyone??!! I need my group!!:bored::thumbup:

[adagray 1]

I am so sorry they are leaving you hanging. But, if it makes you feel any better, it seems that every post I've ever read about a peer-to-peer conference ended up in an approval. Maybe there is just some minor clarification that needs to be made so they didn't want to formally deny and then have you go through appeal.

[Violetflame 0]

Thank you sooo much Adagray. I've never heard of this before. Just another eye opening experience with the insurance industry. :bored: We must remember we represent losses as this is a very much for profit business to the shareholders that own the stock in our insurance companies. I have been denied covered benefits before when medically necessity was met, because of my "habitus". FORGIVE my thinking that medical necessity was the basis for ANY covered procedure!! FYI if you want to reduce your 38FF breasts, you must be at your ideal weight according to Anthem bcbs. The Schnur sliding scale is GOD here people!!

Just keep making your insurance payments and shut up!!! YES I'M PISSED OFF!!!!!!!!!!! No icons to express myself.......

[sue in ne 1]

Stay the course. You are doing fine. The insurance companies make the extra hoops so those who really can lose the little extra weight they have, don't do it instead of diet and exercise. There are surgery junkies, and hospital junkies and all kind of nuts out there who will think this surgery is for them. i initially had a denial based on insufficient information . (my current doctor has a file 3+ inches thick on me and that isn't everything !) The surgeon sent in more and it was approved, conditionally. ( standard practice for many procedures, not just bariatric surgery) After surgery, they had to again review all the costs and necessity- they paid in full, BTW.thought It was going to be only 80 %.

[Violetflame 0]

I am very happy to hear someone has been taken care of by their ins co 100% Sue, and they should!

I just spoke w/my Dr.'s office and she said he was steamed that there was a request for a peer consult. Good!! He is an excellent surgeon and probably does not appreciate bean counters questioning his diagnosis and treatment. It is all set up tho, I should know within a couple of days. Wish I could be a fly on the wall........

[Violetflame 0]

OK, for anyone following this, my pathetic saga continues. ANTHEM BCBS, (the bs part fits) put my surgeon on hold for fifteen minutes today during their "peer conference"!!! I am livid! irate! My Dr is proceding with a level one appeal while the conference is rescheduled......Has this happened to anyone else? I seem to attract difficult scenarios.

[adagray 1]

Oh man, how annoying! Well, maybe if they don't have time to talk to your surgeon, they should just approve it already!!! Sorry you have to deal w/this. Hugs.

[sue in ne 1]

Violet Flame, i personally never had to appeal this. Your Surgeon has probably dealt with more of these situations. Follow their advice. My Surgeon had a Nurse track the process for insurance approval for every one pursuing surgery. The surgeon's office will be able to give you advice and tell you what happens next. BTW, i have BCBS- NE now and switching to them right after surgery was a pain. :tongue:( My job did it; I had no choice) My first fill was delayed over 2 months because they "lost" the information that was to be transferred and would not authorize it. I called HR, and the Dept. of Insurance and ranted (unfortunately at work ) til it was settled.

[Violetflame 0]

Well, Adagray and Sue in ne, my status report is I am still waiting for this peer conference to happen while swilling maalox on ice and sleeping in a chair :crying: (how long can one do this and remain sane?) The position Anthem is taking is "there is nothing wrong w/the band" so, too bad for you.....i think this band may cause more serious problems before they decide there may be something wrong with it, thus medically necessary. :cursing:

[sue in ne 1]

Suggest you see an attorney with this appeal Your surgeon's office may refer you to one. Money is tight but pain is real. I know nothing about peer to peer conferences. You need someone to play their game. Good Luck !

[Bre's Biggest Fan 0]

Well, Adagray and Sue in ne, my status report is I am still waiting for this peer conference to happen while swilling maalox on ice and sleeping in a chair :angry: (how long can one do this and remain sane?) The position Anthem is taking is "there is nothing wrong w/the band" so, too bad for you.....i think this band may cause more serious problems before they decide there may be something wrong with it, thus medically necessary. :eek::cursing::smile2:

I am confused:huh2:...Are you trying to get the band removed?