Combination Vent/Question

I had gone to Dr Carroll's office for a consultation on Sept 29. They took all my info and said they'd send a letter to my ins co. I called a couple of times when I didn't hear anything, and was told that it usually took 4 - 6 weeks to hear back from ins. After 6 weeks, still no word. Dr Carroll's staff told me to call the ins co. I did. They said they didn't answer letters requesting acceptance for lap band surgery, only surgery pre-authorizations, but they would send me a letter with the requirements. I relayed all that to Dr Carroll's office. Still no word. Called again, and they asked me to fax a copy of the ins letter, which I did. Still no word. Called again, and got hung up on. Called again!! (are you counting the calls yet?) Anyway, I meet all the requirements except being on a supervised diet for a year. I was on WW for almost 6 months, that the longest I have a record of. Dr Carroll's office tells me since I didn't exactly meet all the ins co criteria that they won't even file for the pre-certification. Was just told that yesterday - so I have wasted 2 whole months! Very frustrated! Is that normal practice that they won't even file and see if ins would pay?

Ins companies are VERY strict with the supervised diet criteria. It would not hurt to try, but there is a 99.9999999999999999999999% chance you would be told nope, not without the year. I suggest you get on the phone with your PCM asap and start your year now to get it over with =) Good luck to you! Connie

Hey Vicky, The same thing happened with me. I will tell you from experience DOCUMENT EVERYTHING. I wrote down every time I called and what was said. I too needed a years worth of weight loss attempts. I remembered that I belonged to an Atkins website and posted in their forum my weight loss progress for about 6 months and they accepted that. I printed off all the forum pages and sent to them. I then had to account for 6 more months. So I went to my gyne and had them pull records for several years back and everytime they had in their notes that I talked to them about weight loss, I printed those pages and sent them in to Ins. And they too were accepted. They were not even consecutive months or even years. BE PERSISTENT and DOCUMENT EVERYTHING.... Sue

You have the power to talk to your insurance company directly and find out what they will and won't approve. Most doctor offices will file--even if they know it's not approved--to see if they can get anything from insurance. I work in an orthopedic surgeon's office. We precertify surgeries only if we know it requires it. It's the patient's responsibility to find out if precertification is required. Every office works differently. You have to be careful with wording, though. Pre-certification is different from knowing if it's actually a covered service. Pre-authorization is also different from pre-certification. You said "...they didn't answer letters requesting acceptance for lap band surgery, only surgery pre-authorizations..." In my experience, a letter from the doctor's office requesting the surgery is how you go about getting pre-authorization and then on to pre-certification if that is also required. So in Dr. Carroll's office's defense, I'm not sure what else they could have done other than submit the letter. It is then up to the insurance company to throw it back to them on what to do next. Not to say that it didn't fall through somewhere (either from the ins. company end or the doctor office end); but definitely stay on top of it and write down who and when you talk to someone. Get their name (at the ins. company, too) as they are supposed to be documenting each call. I'll tell you from my experience talking to them professionally that they sometimes just give an answer that isn't necessarily true to get you off the phone. But in all honesty, YOU pay the insurance company--so you are the one who has most power with them...not the doctor's office. Feel free to call and harrass them anytime. Sometimes if I can't get an answer at work, I'll call the patient and ask them to call--and they usually get through quicker than i can! mary

Be glad all they're asking for is a year. My ins. wanted 3 years documentation with monthly weigh ins. Who can afford to go to the doc and pay a co-pay every month 3 years? Not me. So I decided to do self pay and am lucky enough to have a Great Aunt who is going to be payinf for the surgery. Good luck to you and I'm so sorry that you've had such a frustrating time. I had the same frustrations with the place I started out at originally. Brandi ;~)