devistated!! Insurance changed the rules!!

I am beside myself today.  I heard from Kat (a great lady with my Bariatric Surgery Center) told me that my insurance-United Health Care- stated that I now need to have 3 years of Physician Assisted Weight Loss!!.   I don't get it.  When I called them in April, I was told that it was 6 months!!  Kat stated that this is what my insurance asked for also.  Why did they now add on this requirement???  I am so upset, angry and confused.  My surgeon is going to appeal this decision on Monday.   Is there anything I can do?  Do I call my insurance company???  Do I write to them????  I am beside myself.  PLease let me know if anyone out there faced this and won??  I have this feeling that I won't last 3 more years with all my health problems.  I want to be able to keep working but I am finding it almost impossible to work out as my ankles and legs are so swollen, it feels like lifting 100 pound weights.  I am working so hard to follow my high protein eating program, but I am not losing a significant amount of weight.   Any information would be greatly appreciated.

Dr. Antoine in Omaha is my surgeon.  I work for the State of Nebraska and my insurance is United Health Care and I am part of the Wellness Program (that alone should indicate that I am trying hard to up my health. 

 

Thanks again,

 

Linda

Wow -- so sorry! I'm glad your surgeon is appealing. Maybe that will work and you won't have to do anything further. I know there are services out there that will help with insurance appeals. (They charge, though.)

Three years is ridiculous!!!!

Never heard this one before, and 3 years of waiting with ever worsening health can't possibly be in your best interest.

Call, and when you do, get the name and job title of the person you speak with a and demand to see this new requirement in writing. And then appeal, appeal, appeal. This is just outrageous.

There must be some kind of gevernmental agency in your state that regulates insurance companies. I would contact them. This is an onerous requirement that can only be beneficial to the insurer by placing a barrier to expensive medical care. It can't possibly be for the benefit of any patient.

Larra

 

When my insurance pulled **** on me my surgeon did a phone conference to appeal it. ON top of that I contacted my HR department and told them how my insurance was doing me and asked them to contact the insurance rep that sold our company the insurance in the first place. Sometimes they can have an impact on such things especially if you work for a large company. THe insurance company does not want to lose business. 

Insurance companies aren't allowed" to change the rules"in the middle of the stream. If they are changing the rules they have to prove it is across the board and not just for you. They have to provide you with a WRITTEN notification of policy change,otherwise it is a stall tactic.

I learned this from Walter lindstrom and his obesity law firm. I would suggest a call to them,free of charge,and they will hear your story and sometimes,just a call from them to. Your insurance provider will set the insurance provider straight and they will approve you. If they think they will need to make a more involved approach on. Your behalf they will tell you that upfront too.

I don't work. For them,and receive no kick back for suggesting them,
. They have helped many many people get approved,who should have rightly been approved in the beginning.

I have recommended them to several on the boards who have been. Successful in overturning their denials. The initial phone call is free,what's can it hurt?
GL

I feel for you.  I experienced this and more games the more I dug into my insurance company to try to get my DS paid for.  It got very frustrating after a while - so keep your cool, and continue to fight them head on.  Let them know you will never quit fighting for this.

Personally, I got so fed up with it all that I self paid.  I had more money than time at that point.  I also had Mexico all sourced out as my second choice for surgery.  I just didn't have the patience to play the insurance games, and I had savings to pay for it.  My insurance company said I had to have a BMI of over 50 (or 40 with comorbidities) for over 2 years to qualify for anything - I did not want to wait another year to qualify because then they would just change the rules of the game and keep me spinning.  The insurance companies know that people change insurance carriers roughly every 3 years.  If they can keep you spinning, you will probably change insurance companies and the whole mess becomes some one else's problem is their line of thinking.

If you have to get the insurance companies to pay for it (or it won't happen), then keep plugging away.  You have to make yourself a righteous pain in their neck every day you wake up - till they give in.  For a while, it was my daily mission to irritate the hell out of them as much as possible.  I was pleasant to talk to, to deal with - but beyond that, I demanded more info and escalated to every level of management I could.

And don't trust anything they tell you.  Always ask for it in writing, always take the names and phone numbers of the people you talk to, and document your phone conversations.  I taped my phone conversations and wrote a ton of letters asking for information, rules, clarifications, etc.  It was a slow and tedious process, but they are CYAing against your request, and you need to break through the shields they put up by digging in and getting your coverage and rights in writing.

Good luck.

Linda K. -

Sorry they changed the game on you! 

I have a Medicare Advantage plan, administered by UHC.  I had absolutely no problem getting my surgery covered, but I did have to attend support group for six months prior to surgery, in addition to following a doctor supervised weight loss plan.  I didn't lose enough to be deemed successful at it, so I got my surgery.  I started the weight loss plan at 405.  On surgery day, I was 397, no cheating.

Perhaps your BMI isn't high enough to justify surgical intervention.  Here's a thought:  perhaps you can get your records from you primary care physician, demonstrating your previous attempts at weight loss through restrictive dieting.  If you've struggled like most of us have, you probably have more than three years of evidence!

 

 

I work for the STate of Nebraska and I was told that my insurance is through a self funded.  Meaning, my State sets up the insurance program and has UHC to manage it.  That said, I was told 6 months and now they send me the paperwork stating that it states 3 years.  BTW- I have a BMI of 53 and tons of comorbs to deal with.   I may have them though.  I have been setting down and realized- our state has a wellness program in which I have been a member for 3 years.  Each year, one must complete a program to qualify for lower premiums.  I have participated in 3 various programs- a walking program, a program where I ate healthy and put the information down on record, and my last program I did a weight loss program.  I also have to get a physical every year to qualify for the next year.  If I can get those records, I have my 3 years ( I hope)    We will see.   Thanks for the advice.

Yes, I fought the battle and won!  

Three years is absurd. Here is the link to United Healthcare's Statement of Medical Policy for Weight Loss Surgery. This is their internal guideline for approving surgery. https://www.unitedhealthcareonline.com/ccmcontent/ProviderII /UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf /Tools%20and%20Resources/Policies%20and%20Protocols/Medical% 20Policies/Medical%20Policies/Bariatric_Surgery.pdf    On the bottom of page 3, you will see a bullet point that states you need a minimum of 6 months of physician supervised weight loss---not 3 years. 

I faced a similar battle. I started my physician's program in Nov, 2012 and was told my insurance requirements did NOT include any such 6 month program. The surgeon's office insurance verifier was supposedly told that by a UHC rep over the phone. In July, after completing all my other requirements, the office submitted for surgical approval and it was rejected--for lack of a 6 month supervised weight loss program. ARRRGH!  To say I went ballistic is a gross understatement. After a flurry of phone calls from me and from the dr.s office to the company that does the reviews and approvals for UHC and to UHC, I talked to someone in the UHC's appeals office who told me about the above document. I also called the Walter Lindstrom law office in San Diego which specializes in weight loss surgery and related appeals and got great free preliminary advice from Kelley Lindstrom.  (Google them and other WLS attornys.)

Afterwards, I wrote a 2 page, unemotional appeal letter filled with facts about the requirements supposedly set by UHC and transmitted to my surgeon and relayed to me. I had started in a WLS program run by Pacificare (my insurer bought out by UHC) around 2006 and continued in that program until the insurer discontinued the program--because they found it did not work!  Several studies have been done that show these programs are not very effective in getting people to lose weight. However, ins. companies continue them to 1) save money on surgeries, 2) get participants used to the rigors of limited foods and mandatory exercise that they will need post WLS and 3) weed out the people who think WLS will be an easy out and they can continue their bad eating habits after. It was then that I discovered that my surgeon's office HAD the same Statement of Medical Policy in their files. The trouble was that no one on their dumbazz insurance staff had ever read the requirements through to page 3!!!  And it damn near cost me my surgery!  Then I had a phone chat with the Chief Operating Officer of the Hospital which sponsors the Obesity Center Program about how their staff's negligence had cause my surgery to be denied and mentioned in passing that I had been reviewing the matter with an attorney specializing in WLS. I was non-threatening, but I suspect the chill in my voice caused her to reach for a sweater. 

I did go through a formal appeal process and the UHC nurse in the Appeals Dept. preparing the appeal called me with a couple of questions before she submitted it to the Medical Director. In very even tones, I explained  how severely my co-morbidities were impacting my work and daily activities. Almost as an afterthought I mentioned my participation in the 2006 ins. company sponsored program. She added that to the appeal and that was the frosting on the cake to get the denial overturned. Chatting with that nurse, (who was very professional and also very compassionate), it was clear to me that I needed to set my emotions aside and deal with this as a contractual matter. I very carefully reviewed my insurance documents to make sure I clearly understood them so I could be sure to bring up any discrepancies as I talked to the various people and companies involved. Be very business like in your approach. They have heard so much whining and wailing and gnashing of teeth, that I suspect they are relieved to talk to someone who is well informed, level headed and determined.

Your surgeon's office may or may not be willing or able to help you with an appeal. They should be motivated to help you get the surgery because that's how they earn their money, but some offices are so busy they won't take time to deal with tougher cases. Some staffers are not much more than minimum wage clerks. Talk  to the most senior and professional person on the insurance staff of the surgeon's office. Talk to the insurance administrator for your office or employer--a very important ally. If necessary, ask who you can call at the next level to get more help. Keep very complete notes of each and every conversation.  Get a free initial phone consultation with one or more attorneys specializing in weight loss surgery problems so you get an understanding of how the system works. Do not take no for an answer, just keep asking who you need to talk to and what you need to do to get this overridden.

Finally, UHC is withdrawing from some HMOs in several states where they don't have enough people insured to be able to successfully compete when the Affordable Care Act takes effect. Instead they will concentrate their marketing in states where they already have a large market share.  In my case, I had been notified in June that my UHC private HMO coverage will end 12/31/13 as a result of UHC's new marketing strategy--so I would not have been able to complete a 6 month program, much less have the surgery, before my coverage expired. The perfect Catch 22!   I don't think this sort of thing is likely to affect your employer's program  if they insure all Nebraska state employees, but it may have something to do with the supposed change from 6 months to 3 years. Be sure to go over this with the insurance administrator at your employer's office.  You may find a way to work around this.

Let us know how things are going. I will try to follow up and help if I can. 

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