another question

I have been doing some research online and on obesity help and have come up with yet another question about insurance.  I read somewhere that said although UHC might cover the insurance that the company might have it excluded on their end.  When I call the insurance company and give them our insurance id and everything and he tells me that yes, it is covered as long as I meet the requirements does that mean it is covered or would he not know if the company excluded it?  It seems it would show up in our account that it was excluded but if that isn't the case where would I find out if it is excluded through the company?  Thanks again for your replies and being so patient! 

He said your covered as long as you meet the requirments. He would say your policy excludes it if it wasn't covered. He can see the policy. 

I know how you feel I called 3 times and talked to 3 different people to make sure. If you're more comfortable call again and when they say "it's cover if..." say so it is not excluded from the policy as long as I qualify? They will say yes.

But I really think your fine. They are quick to tell you if you have no chace in hell of getting it.

HTH

Ok lets see if I can tackle this....  

 Blue Cross of TN takes the approach that they will NOT cover wls. They "exclude" it... UNLESS a company like my employer specifically tells them "yes we DO want to cover wls".  Then special guidelines are set into motion for wls to be covered for that employer's folks.

 UHC is different than BC.  They take the approach, "Sure we'll cover the surgery".  There is no exclusion up front...  BUT, again it is employer driven.  If the employer does NOT want wls to be covered, they tell UHC that they want an exclusion.  

You should be able to call the toll free number on your card, get them to look up your account, and specifically ask, "Does my employer allow me to have (insert your surgery type)?  If so, what criteria do I need to meet?"  Try to get a copy of the criteria.  Then go from there.  I sure hope this makes sense.

I have United Health Care through the City of Memphis.  I had RNY and was approved around last October.  I had RNY on 2/9 and they have paid. 

When I called the toll free number they told me the same thing that they told you.  That their basic policy paid for WLS  if I met the requirements, but the employer could exclude it in their plan. Since the City of Memphis was such a large employer, they had a person at UHC that was familiar with the City of Memphis coverage and could take the calls and answer any questions I had.  If I had been from a smaller company they would have me contact the employer's benefits department and talk to them directly.   

Once my DR. submitted the request for approval, I got a letter in the mail that stated it was approved and  gave it to my WLS surgeon. 


I would call UHC back and ask them if they could tell you if the employer has excluded WLS.  IF they can't tell you, call the benefits department of your employer. 

Thank you so much cathy and everyone for your wonderful advice.  The most amazing thing to me is that you get different answers from every different person you call..it's so frustrating!  I called both the company where my husband works and the insurance company and they both stated to me that it was not excluded on either end.  As long as I meet the three requirements then I have a chance.  When I read all the other posts I get disheartened though...I mean, some people you would think they would most definately approve are not approved and others that are on the line get approved.  I got my letter of necessity from my main doctor today and he updated my file and he said sometimes he wonders if they don't just close their eyes and say this one will be approved today.  It's just a shame.  Every person I have read about on this board has a story that if people really listened to would never have been turned down.  It's just hard on the nerves and I've never been a very strong person...I hope I can go the long haul and fight if they turn me down.  One question I keep asking is that with UHC  you must have 5 years documentation of morbid obesity .  The guy yesterday told me that just means at least one time in those years if I went to the doctor and they took my weight that was all I needed and that it didn't have to be years like in order but could be 2002, 2003, 2005, 2008, and 2009...well the woman I called today said they had to be consecutive 5 years straight.  I got so discouraged...i was nice but I told her forget the five years..I've been overweight my whole life! lol

I know for a fact UHC does not require 5 years in a row. Because mine were 2001, 2002, 2006, 2007 and 2008 (I fell out of the BMI range 2003-2004 so we omitted those years).  And as far as UHC the people *****view and decided if you will be approved is the Coordinated Care Department (unless your employer paid extra for a nurse case manager to manage care like this my husbands didn't). If you really want to know what they are looking for call them. I bypassed customer service for the same reason your talking about to many different answers. And when I called to check on it I call them them as well. I don't have the number on me at work it's at home, but I will be happy to post it later if you'd like it.

HTH

Thank you so very much..I would love the number!  I am glad to hear that you didn't have to have a consecutive 5 years back because I know it would take me at least 2 more years to get that.  Congrats on getting your approval! 

One more thing...I went to your blog (it's very informative to read your blog)  and I read where you said one of the terms is to have at least one co-morbidity...thay haven't mentioned that to me and I have asked several times.  I have 3 which are bmi over 40, at least 21 or over and 5 year documention that shows I fall in the weight range of morbid obesity.  Is that possible to both have UHC and have different requirements?  Do you know if depression is considered a co-morbidity?  I was diagnosed over a year ago and am on medication for that and pre diabetic medicine as well. 

Sorry I have been asking so many questions...You all are so supportive and helpful that I love asking you questions!  I keep thinking of new ones lol

Also I think you might want to murder me cause I won't leave you alone but now I have a comment to make.  I wanted to comment on your blog but it doesn't allow enough space lol  I read all your requirements and what you said you had for proof to the insurance company so why would your doctors  think you would not be approved and they be shocked because it seems to me you did everything and fell in all the guidelines???  It seemed to be    you had done everything right to get it ...oh and I am so sorry that you are having to wait so long...I could feel your frustration through your blog...I am a very impatient person and I would have no hair left now.  I have been trying to tell myself if I get turned down to keep going but I am so impatient..i just don't know what my reaction will be....congrats!

Many of us have had insurance problems... and it is SO very frustrating! But I will tell you that those times really showed me how badly I wanted the surgery!  One person on here over a year ago said that he decided that he was going to take his settlement and instead of spending it on weight loss surgery (his insurance denied him), he was going to build a new garage with some weight loss workout area and equipment.  This individual was going back to give "the hard way just one more try...."  I do hope he lost his weight and was successful.  But I always believed, if a person can just walk away, even if the ins. co says no, and not put up a fight, file an appeal, take it just as far as possible...  then really they weren't ready.

Now the question was asked why the insurance company keeps denying or holding people off.  MONEY.  That is the bottom line.  Let's say the insurance company has to pay the hospital $25,000 for your surgery.  The longer they can keep your claim in review, or "processing" or "pending", the more interest is made on the insurance monies set aside by employers.  Now i am not 100% sure who gets the money...  the employer who has funded it, or the insurance company...  but somewhere along the way there has to be some type of reward for being so frugal with the money.  

I work at a hospital and used to do billing/insurance collections.  Some companies are also very slow in making payment even after the claim is filed.  And, another trick they use or utilize is that they change their requirements or guidelines on services, saying that they have to be authorized beforehand...  managed care companies are bad about this and try to change their rules OFTEN. That way hospitals, doctors can't keep up with all the changes.  If a patient goes ahead with the test, and all the loops haven't been closed, guess what?  The patient does not pay; the insurance does not pay;  hospital or doctor has to write it off...  

 Sorry I got off on a tangent!  But I get angry at insurance companies.  That is an issue that runs pretty deep.  I still remember my fight with them and its like being in a black hole.  Endless.  But don't give up; keep fighting and if you should get denied, pursue it further with an appeal.. .  they will tell you exactly what is lacking and then you can be your own advocate and provide what is needed...  even if you have to go to every doctor you've ever been to just to get copies of all your file.  I had over 115 pages of documentation that I collected from several doctor's offices...  every single time the insurance company said I did not have something submitted, I faxed it to them myself.  I called them and made sure they received it.  I took names of the reps I spoke with.  I had an excel spreadsheet a mile long...