Insurance Help

Hi, I have not posted here in forever. I have been dealing with trying to get the surgery for several years now. Last year my insurance became Blue Care Network. I found out they require a year of supervised visits with a doctor...DID that...now my doctor sent in the request and they sent me a denial (no appeal letter, which I had to call and request but was to late to send in) but they said they did not recieve enough information from my doctor so she resent some information and they are now saying that I need to make life changes at home before they will re approve merdia or approve the surgery. Has anyone heard that before??? I am so frustrated. I want to call them but I know they will not give me the info I need. This is only the third patient my doctor has worked with as far as the surgery, I dont know if she does not know exactley what to do or if the insurance company are that much of idiots that they would say I need to lose weight before they will approve. (that is how my doctor took what they said, she thinks they want me to lose weight first) we all know if I could lose weight I wouldnt want the surgery...Any help or suggestions would be appreciated. Thanks Melissa

If they denied your doctors request for a referral to the bariatric surgeon, then you should be able to appeal. There has to be an appeal process if you are not happy with the answer you got. I would call BCN and ask them what their grievance procedure is and go from there. I have HAP. Like BCN, you need a referral to see anyone other than your PCP. My PCP requested a referral and I was denied. I got a letter stating I was denied. I have 2 years from the date of that letter to initiate an appeal, which Im in the process of doing now (hopefully it will be in the mail by Monday). If I am denied my appeal, I have one more chance to appeal to a higher level within HAP, usually this is an in person appeal hearing, though you do not have to go to it if you don't want to (but its a good idea to go). If for any reason they would still deny surgery, the next appeal level is the state insurance commission. So, find out what their appeal process is, even ask them to send it to you in writing and file an appeal and keep appealing as far as you have to go.

Oh Sweetie Im so sorry you are having such a hard time with BCN. I have BCN and it tooke me about 14 months to get a yes answer from them. Like many others they denied me. They said I did not go to the doctor enough times to have weight checks. So over a year I went to see a dieticain everymonth and my pcp every month so there would not be any more exuses. I had everything in order but they still said no after a year. When I started the appeal process the second time around one of the ladies from BCN assured me that I had all of the info I needed. But the doc that decides if I was going to get it said no again. The lady from BCN encouraged me to write another appeal letter and fax over my diary. I did that on a Friday and they called me Monday saying I was approved. The best advice I can give to you is to be persistant and dont give up. The diary I faxed to them was very explicit but I figured if it would get me approved they could hear about every aspect of my life. Stay encouraged Dayja surgery date: 4/17/06

As an nurse coordinator for a bariatric program- I cringe when a client comes in with BCN. I tell them upfront that they need to be prepared to stick up for themselves and not to give up.I tell all of our BCN's that it will be an automatic 2 appeals and then a panel review. It's not a quickly resoved process either. I still have one lady thats been fighting sence August of 05. But all is not lost. I have sat in with clients on a panel ( by speaker phone) and I feel it's more of an intimidation tatic. The BCN panel made up of nurses, doctors and contract people that were very nice. They asked questions directly to the clients and they are notified in 10 days qbout the result. Your commet about lifestyle changes and medications does suprise me, Wow. (I havent even heard that one). The interesting but unfortunate part is that the rules can change without program or subscribers being notified. I have 2 new BCN clients and explained that the circus is just beginning and patience is a must. Don't give up. Sandy B.

sandy, i just got everything turned in now i have to wait i have great lakes-medicaid do you think i will have the same problem? i have type 2 diabetes-bmi48 high bloodpressure-150lbs over weight . [email protected] thanks barb

Barb, Medicaid plays under a different set ouf rules. Some are, repeated failure of wight loss by medical management, absence of alcohol and drug abuse, absence of significant psychiatric disorders., psychological assessment. Often times Medicare is a little faster. Are you at a center that is "ceritified"? That is a new law sence February. Good Luck! Sandy

sandy, i was told it was certified it is the center for comprehensive weight loss.i never have had a alcohol or drug problem or psychiatric problems either. i seen that some people were approved without proving the dieting part. i wondered if it was because they had so many medical problems i emailed a couple of them but nevered heared anything from them. thanks much barb