XPOST - Get this!! Insurance now refusing to pay??

 I get my explanation of benefits in the mail that I normally receive after every time the insurance pays out benefits and they are not covering my DS procedure???    How can this been after everything that was gone through pre-op and receiving approval before hand?  Has anyone ever heard of this??   I have keystone HMO and I spoke to them last night and they stated that code, for a 'restrictive gastric procedure' was an exclusion on my policy.  WTF?  I specifically seen and remember speaking to them on the phone and received approval for exactly that thing.  How the hell could this be happening.  The lady was nice on the phone and said to appeal it and include everything we did pre-op and the fact that they paid for everything else.  Hospital bill, anestesia, everything but this one piece of it, which is the Surgeons fee for the procedure. 5,500$$.  But I mean what the Fuck!  Sorry, had to say it. 

I guess I am thankful this happened now and I at least go my surgery, as opposed to all of you who have to fight for it, but jeez, what the hell is going on here.  I have a call into the insurance person and the docs as well.  I will keep you all posted.

Sounds like more of an accounting error to me.  I would contact the Surgeon's office and tell them to help fight this for you.  Since it's after the fact, it's in their best interest to correct this.  Try not to panic....Keystone is excellent insurance and usually an easy pay.  I'm sure it will all work out.

Congrats on your surgery!

Kat - So sorry to hear that you are battling this now! Do you have a copy of the approval letter? I agree with Eileen, gather all your info, get the surgeon's office involved and FIGHT FIGHT FIGHT - squeaky wheel gets the oil!

Best of Luck!

Liz

Thanks all, I am going to take a wait and see attitude for now.  I will see if they billing dept will fight it at the docs office.  I did talk to them and she said she never got a call like that before, but that it does state on the approval or pre-cert, that it does not guaruntee payment, what the hell is that?  Sheesh!!  No one has sent me an actual bill yet, so I will wait and see what happens.  Thanks!

I'm not a billing specialist but I did work for BCBS for 10 years and it sounds to me like this is just a matter of the office billing the insurance company with the incorrect code. I believe the correct coding for DS is code 43845: Gastric restrictive procedure, with partial gastrectomy, pylorus-preserving duodenoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)

There are quite a few billing codes that fall under surgical treatment for obesity and if the office billed with the wrong one, then the insurance may not be covering it because A) it may not have been specific or B) it could appear to be a procedure which very well may not be covered under your policy.

Call the surgeons office and ask them to check your billing records and for them to follow up with the insurance company. They'll definitely get this resolved for you rather than risk not getting paid.

Good luck!