Denied

I got a denial letter from FED BCBS, stating that I am denied because they will not cover my surgery if I stay in the hospital.  This is for Lap Band, they only cover if you go in as an out patient.  But my surgeon has all of his patients stay a night in the hospital.  I can't believe that one night hospital stay makes a difference.  WTF.......My surgeon is not willing to fight the insurance company, so I have to do a self appeal or find a doctor that does outpatient Lap Bands or go with RNY.  The letter stated that they will not do anything just for the convenience of the Doctor, patient or facility.  They feel that the Lap Band should be on an out patient basis.  My doctor refuses to let me just go in and come out...I suppose he is only motivated by money.  It really sucks....because he is a so called "good" doctor.  It's only one night...what is the big deal.  I understand where the insurance is coming from...sure I can stay if there are problems...but if not they do not see it to be necessary.  I really don't know what to do now.  I am a government worker, this appeal can go all the way up to D.C if I want it, but by that time I can lose some weight on my own.  I just don't know...my BMI is 48.  I really want the surgery, but I have to start all over with someone else who does lap band out patient or RNY. jeez...... I don't know where to go from here..........

APPEAL! My docs office told me that it is rare for folks to appeal an initial rejection, but for those that do, virtually all of them get approved on appeal. Also, there's something like a "less than 24 hour stay" that doesn't actually count as an "overnight" stay, even though you are there overnight, so you're still admitted as an outpatient and there nearly 24 hours.  That may be what your insurance co. is talking about.  Something like "observation."  Perhaps you can wiggle into that scenario somehow.... if you have surgery at 10AM but get discharged at 7 or 8 the next AM.  Talk, plead with the surgery coordinator at your doc's office.  He/she should know all the ropes of how to deal with these nuances of insurance companies. Just don't give up yet!

And don't think your doctor is only motivated by money.  Gurl, he's looking after your HEALTH.  Believe me, if he thought it SAFE to throw a band in you and send you out the door for the sake of insurance, he would.  He gets money on that procedure as well.  It's the insurance company you should be frustrated with, not your doctor!  If I were a doctor, I wouldn't throw a band on a patient and throw them out the door either.  Any number of things need watching for a period of time, even if brief!  This is your body and health and it seems your insurance company is taking a big risk with it by wanting you out so fast. And just some food for thought... I don't know your personal weight situation, but from my personal research AND being told by 2 doctors, because I needed to lose in excess of 100 lbs. all my research and those 2 docs told me I probably wouldn't be happy long term with a band because the lap band is typically for folks with lesser amounts of weight to lose.  I was very disappointed because that's what I "thought" I wanted, but the more I read and studied and talked to two different experienced physicians, the more I realized that RNY was the better option for me and the amount/long term loss I needed. (I'm in the neighborhood of needing to lose about 140ish lbs.)  Both docs told me they believed I would be unhappy down the road with the band because I wouldn't lose the weight to get me where I need and want to be.  (Because with either procedure, folks only tend to lose 60-80% of the total amount needed to be lost.)  So even though I was VERY disappointed at not being a good lap band candidate, I'm SO glad now I did RNY so I should be able to get closer to the goal I need and want to meet.  Just some food for thought for you... Good Luck with your journey...

When I worked at a local hospital, they had a classification called "Outpatient Observation" and it counted as outpatient even though you spent the night in the hospital.  The patient would check in with an "Outpatient Surgery" classification, then in admissions we would later change their status to the "Outpatient Observation" and as long as they were not under that status for 24 hours, they never went to "Inpatient" status.  You may be able to get around the system that way.  It would satisfy your doc and insurance.   I certainly hope you appeal if that does not work!

It seem the doctors office is frustrated because they said they got into a shouting match over the phone with insurance company.  The nurse told me that doctor "does not feel like going through it with the insurance". Those were the exact words..so that is why I got pissed with the doctor because I am sure this is not the first denial or negitive response from an insurance company.  It's like they are not willing to fight.  She was like well "have you considered RNY".  I was like yes, but I an not just going to change my mind based off of what you and the insurance want.  

I cannot blame you at all for being angry.  I would be angry also.  Another doctor may be the answer.

Sheesh, how frustrating!  My surgeon only does Lapband outpatient.....contrary to the money, I would think that by doing it outpatient would give him better ratings,, but then again, Dr. Harris is new to Lapband, so maybe his reasoning is he hasn't seen the overall necessary hospital time needed yet........Dr. Bauman said he wanted me in and out asap to prevent me from being subjected to anymore germs than I had to.....I'd say appeal first, then seek another Dr. , but I would not change surgery types if that's what YOU want.......you're the one who has to live with it- not them!  Maybe for some reason, this wasn't meant to be with this Dr.?????......never know.......... Nancy

Well, you have a few options - you could speak to the hospital and see how much they would charge you if paying OOP for the hospital stay - see if they will agree to let you pay their typical contracted rate with fed BCBS and work out a payment plan. Once you find this out you could see if its worth it just to pay the hospital OOP. You have the option to appeal, so do it. Yes you could lose weight on your own... but can you keep it off? Thats pretty much everybodies issue who has any sort of WLS surgery - we are EXPERTS at losing, but are horrible at keeping it off.  The surgeon may let you go outpatient if you sign a liability waver.. basically taking your health into your own hands. I do not believe he can force you to stay overnight but he could refuse to operate. If you are willing to accept responsibility for not staying overnight he may say ok. I would not say your surgeon is motivated by money - he doesnt get paid any different if you do stay in the hospital or dont - the hospital would be the one who gains financially from it. His decision to have you stay outpatient would soley be based on his feelings as for what is best for the patient. RNY is never done outpatient - I would say your insurance would cover 2 day stay... as for lapband I am not sure. You have to decide if you really want another surgeon - when I met my surgeon I knew he was the one for me and I wouldnt have gone anywhere else. To me paying any additional money would be worth it to go with the person I felt was the best.

I read over a few responses and wanted to say this - observation stay is 23 hours or less - not a minute over!  In some cases it still requires authorization from the insurance company... it is not considered the same as outpatient since when you are under observation you typically are moved to a room and will cost them more. Still it is another good question to ask the insurance company!

I just have to get it all together and figure out what is going to work.  I don't want to get denied again.  This is just such a crazy reason to get denied for.....ugh!  I am just so frustrated with this process...every step of it has been a hassle....or issue. 

I had Dr Harris do my rny and I only stayed overnight but when I got auth from tricare it stated that is was outpatient proceedure, not sure who you are dealing with at Dr harris office but I would ask them if its been coded right. but then agian I did rny may be different.