Insurance

Please help. I have blue cross blue shield of illinois ppo. I started going to my doctor in march of this year to have my information documented. In october they changed the guidlines to six months of supervised diets. I had already 8 months. They also said you need five years of medical records. I didn't have that because I have been seeing my doctor for 31/2 years. Prior to that I was self employed and didn't have insurance. I also had my primary and endocrinologist write letters of medical necessity. I was told today blue cross denied me because i don't have five years of records and I didn't have the proper documentation from the doctor. Has anyone else had this problem and its there any way to fight the insurance company. Should I do it myself or have the surgeons office do it for me. Help. I feel so defeated.

I would say that you do it together with your doctor's office. Ask him to write a letter in response to your denial and then you write a letter also. Then you may have to get an attorney on board to help because this may take some additional professional help. You should get a letter in writing stating why you were denied. Then when you write your letter you can address what was said in it. There are books that help you write these letters. Try Barbara Thompson's book and Dr Simpson's book they deal with this situation. You can get both in the store on this site. You may want to also try Weight Loss Surgery for Dummies. I gave my copy to my sister and I believe that she use that book to help write her letter in response to her denial. Chris

Gayle, additional suggestion. You may want to post your question on the main message board to see if you can get any ideas on how to beat your denial and also copies of other's letters to their insurance companies so you know how to format your letter. You may need to post a couple of times because that board moves fast and some people may not see you question if it gets bumped down a couple of pages. Chris

Dear Gail: I have BCBS of IL PPO. I was initially denied due to the 12 month diet. I began seeing my pcp in Dec/Jan of '06. When I found out about the change to 6 months, I called the person on the denial letter and asked her about it. She had me send the diet records directly to her, she put them through and I was approved a week later. The trick was to get denied first, then deal directly with the denial department to work towards an approval. Blue Cross IS VERY STRICT about their criteria. By dealing with the denial department directly (even 9 months later.....) my file was still in their system saying that the only thing needed was the documentation of the diet. My surgeon's office would have "resubmitted" the entire file, and began back at step one, which may not have turned out favorable. The trick is to get ONE person (preferably the one who signed you denial letter) to work with you. Do you have ANY medical records from before you were self employed? If you have been obese for longer than 5 years, evan OLD records will do. The other posters are right though, you should also contact Lisa Madigan's office. They have an insurance area that can help you with an appeal. Good luck, and remember........"NO" does not mean "No" forever, it just means you will have to fight harder..... Dawn

Hi Dawn, Hope you are doing well, just read your reply-for INSURANCE, I too have been denied from bcbs ppo il, I just received my letter yesterday 1-13, and it does seem right to be able to call an actual person, that is on the denial letter, only I don't have one, my letter states-Sincerely, Customer Advocate-u264068, thats how it's signed, maybe I need to call an ask for that-if its an actual person, also, they only have their 800 # on it. My reason for denial is 'BECAUSE THERE IS LIMITED DOCUMENTATION OF ACTIVE PARTICIPATION IN A COMPREHENSIVE NON-SURGICAL WEIGHT MANAGEMENT PROGRAM' I have been in my program going on 9 months, and all that was faxed to them, do you think this could be, because I yo-yo'd on the program??? any other suggestions????? Thanks for listening-just trying to get as much feedback as I can. Mina GO BEARS!!!!!!!!!!!!!!!

Dear Mina: I do remember that the first denial letter does not have a person on it. Just call the 1-800 number, ask for that customer advocate (but you may wind up with whomever answers....) and ask them EXACTLY what documentation is missing. It may be that your doctor missed a page or something minor. The other thing that I did was submit a form of my own for each month showing what my goals were for that month, and which goals I had met from last month, etc.....this was to make supplement my doctor's notes in case she did not take detailed enough notes. I can email you a copy if you would like. Just let me know. As long as you have your doctor's chart records for 6 consecutive months---they mean once a month, every month (no skipping)--you should be OK. They almost always deny the first time, just to see if you are really serious, I guess. The yo-yoing should not matter, because if we could lose all of our weight the "normal" way, we would not need surgery. I am doing well---wouldn't change a thing. Good luck, and if I can help in any other way, let me know. Dawn