Dr. office messed up on insurance precert! Being told I have to redo whole program over!

I started my journey to getting bariatric surgery last May. I turned all my information in to the doctor's office the same week I had my orientation class. At my first doctor's appoinment, they went over everything with me and gave me copies of all these papers and had me sign this letter stating what was required of me to be able to have this surgery. I followed their program religiously, driving 1 1/2 hours one way each time I went to my doctor appointments, my nutrition classes, and my behavioral classes. They submitted all my information at the end of November 2006. In January, I finally found out that the insurance was denying my surgery becaue I had not followed their program. Apparently the doctor's insurance department did not call the precert number on the back of my insurance card. My husband works through a union and has insurane through IN Laborers Welfare Fund. They use ICM to do their precert and Anthem BCBS for "administrative claims payment services only" (I'm taking this right off the back of my card). I have talked to my doctor's office repeatedly about this and gotten nowhere. I have been told that I need to "let go of my anger" and "move on". For some reason, they just don't seem to understand why I am upset over this and have a hard time dealing with having to repeat this program again, driving back and forth 2 times a month at 1 1/2 hours one way each time, with gas prices at almost $3 a gallon. Wow, I can't understand it either. I must be just a mean, hateful person, huh. Oh, did I forget to mention that when I talked to the doctor about this and told her that they did not contact the right people for precert, she went and spoke to the insurance dept. and was told that info was not on my card. I had my doctor look through my whole file, find my card, and I showed her exactly where it was, that it said "Pre-certification" and had an 800 phone number for them to call and that it was not the one they called to begin with. I believe that the insurance department saw "Anthem" and did not bother to look any further. Now I am the one paying for her mistake, but hey, I should really let go of my anger. What am I suppose to do now? What choice do I have? Either continue the program with this doctor or give up and stay like this the rest of my life, however short it will be? I am very discouraged and don't know where to turn to now. My husband has been laid off since February, we have 3 kids, and my disability still hasn't come through after almost 2 years. Some days it's all I can do just to get out of bed in the morning. We moved to a very small town last year, and I don't know anyone here. I feel so very isolated. And I know my husband doesn't need me to continue leaning on him so much. The only good thing that has come out of this so far is that through my last doctor's appointent I had lost 65 pounds. YEAH! My pants are falling off of me; I have to keep pulling them up. Even my sweats are baggy. I don't know what it is, det, stress, nerves, or what, but I never lost weight like this before. Jeez, I'm gonna shut up now. I apologize for going on and on so much. That's been building up inside and needed to come out. Thanks to everyone who took the time to read my post. JC

If you don't mind me being nosey...what doctor/clinic are you going to? Maybe you could request all your records and try a new surgeon. Will you insurance give approval if it is done currectly this time, but you have all of your old info? Good luck, you are in the right place for support.

JC, Im not sure I have any suggestions but I feel you pain and your anger and I dont blame you. I wish there was something that could be done. Maybe if u tell them u decided to deal with your anger by filing a lawsuit they might be a little more willing to start helping u file things correctly now???? Just a thought. I hope things get better for you soon. Pamela

Jenny, I certainly understand your frustration. Personally, I would do as suggested and seek a different surgeon and have them request all of your records. You MUST be able to have total faith in your surgeon and their office staff through-out this journey. It doesn't sound as if they deserve that from you. I would move on...by moving on to someone else. I'm quite sure Anthem has several that they would approve of for you. It varies with each insurance depending on who the insurance is through. I also have Anthem, but my company may have stipulated different coverage approval standards than your company. The best thing to do is for YOU to call your insurance (number on the back of the card). Ask them to send you information for their policy on weight loss approval. That policy will state what all you need to have together. Also ask them if they have a list of approved surgeons/hospitals. For mine, I could have went to anyone I chose. You do have a choice. I wouldn't remain angry though. Anger gets you no-where. It will only add ill feelings with the surgeon. You already have that...so let the anger go by letting the surgeon go. If you need some advise on surgeons/hospitals, there are links on the left side of the screen (the blue section) where you can check out both. Best of luck. Smile, be happy. You were denied because of an office error, not due to anything you did/didn't do! If Anthem didn't want to approve you due to too low of a BMI, not enough co-mobidities, or any other thing, that would have been included in their denial summary. Once you go to a new surgeon and they have the documentation Anthem requires, approval should come quickly. You won't have to start at square one. Sherri

APPEAL!!! A similar thing happened to me. After jumping through all the insurance company's hoops I was told they changed their rules and I would have to start all over again. I appealled this decision and got the program changed to give me credit for the time/effort already put into it. Call your insurance company and ask about their appeals process. Until this happened, I didn't know you could even question their decisions. You have the right to appeal and most appeals are honored. Best wishes. Don't give up! Annette

Jenny, Hi! I have Anthum, & did have to jump thru lots of hoops to get approved. My first time at trying, I did 1 yr. of weight loss with the Dr.( not as sucessful as you were),went to all of the support group classes, and then found out my Dr. didn't support my desire to have the surgery, & didn't turn in all of my records to ins. Oh, was I I was in the dumps for 2 months then decided I had to make a change for the better.I found a new Dr. who supported my decision to have Bariatric surgery- did all of my paperwork, approval letters, & after 6 mo. of weight loss attempts with him, was approved in 7 days! Remember, this is your life, and you are important- so--keep smiling on the inside, keep a positive attitude, and keep trying! There is hope girl- just hang in there & call your ins. and see who they DO approve. Be sure to have all of your papers,transfer all of your records, and meet the Dr. beforehand to really see if they are someone who understands and supports YOUR decisions, if you decide to change Drs. All the best, (((hugs))) Ellen