Gettiing employer to add surgery to policy

[Sandy3 0]

I posted Angry and frustrated in Toledo. I am new to this site. I have Paramont insurance in Ohio. They recently signed a contract w/Dr. Duckett to pay for lap band surgery. Currently it is excluded from my company insurance policy. (It seems mainly because Paramont was not includiing it is any policies). Can people please share any experience they have had in getting their company to add the surgery to their policy once the insurance has made it an approved procedure. Any advice on what to do? I have access to letters from PCP and cardilogist plus therapist indicating that the procedure is medically necessary. I plan to present these to my employer. Anything else I need to do or know to speed up the process? I have been working on this for a year, waiting for Paramont to sign a contract w/the Dr. only to learn that now I have to convince my employer to include it in our benefits (before they possibly change to a different insurance company by the 1st of the year).

Thanks

Sandy3

[sarcar 0]

Sandy,

I'm not sure unless you are self-funded that the employer can eliminate this surgery. When you purchase an insurance plan, the employee usually doesn't dictate what they will or will not pay. If it is a self-funded plan and just handled through TPA to make sure that the checks are paid and you are getting all the certification you need before surgery, then that is a different store. My insurance covers it but I had to jump through hoops (without my employer) to get this done. Others may have more experience with this - but continue checking and the first question I would ask your employer is if you are self funded. That will tell you a lot. Carolyn

[Sandy3 0]

Sarcar:

You are absolutely right. My employer is fully funded not self covered. Therefore it is the insurance co who dictates if the service is a paid procedure. The insurance rep explained to me that the contract they signed was w/self insured companies. The insurance company will provide services as if the procedure is covered, but when the bill comes, the employer will pay for it.

I am hearing through the grapevine that the insurance company has paid for Gastric Bypass. In fact, I contacted the insurance company and said that I needed a denial for WLS. The lady said "Our company does not approve for WLS". I said " I know, that's why I need a denial letter." She said to have my PCP send in a referral for WLS. She then said "I believe Dr. Patrick White does that surgery". I said "Yep". (that's the guy I have heard they have allowed other Paramount members go to for the surgery. ) Problem is that he has an age cutoff of 50 something (I am 61) and that he only does By-Pass (I want Lap-Band). So now I know to ask my PCP to send a referral to the insurance co so I can get a denial. Then I will contact Obesitylaw.com and procede through the process. I am gleaning lots of information from all of the WLS sites and am gearing up for a battle. I may end up a self pay but I will continue the fight, up to and including contacting the people with the power to change legislation in Ohio. I may even see if there are others in the same boat who would like to see this discrimination against us stop.

My therapist's office said that after Paramount signed the contract w/the Dr.'s who do lap-band, that his phone rang off the hook. Individuals were scheduling the required psych test. A few days later, a number of individuals called back to cancel the psych indicating that the procedure was an exclusion on their company policy. The surgeon's office said the same thing. When I asked the insurance rep at the Surgeon's office what happened to those people when they found out they were not covered she said "I don't know. They never called back" (I think she was making a hidden slur regarding my character lol) Little does she know that I am hopeful that I will someday get banded by that doctor and the bill will be paid by Paramount!

Anyway, that's my story and I'm gonna stick with it!!

Thanks

Sandy