WPS insurance

Hi everyone, Anyone have WPS insurance PPO or Other WPS? What did you do to get them to cover your surgery? My ins, switchs to WPS PPO the first of the year. I have talked to them and they tell me that they won't cover the surgery. Said that they don't feel that it is helping people and needs to be researched more. I have tried for the last 2 years to get the surgery from BCBS and Mercy Care with no luck. Can anyone help me out? Thank you for your time. Jim

Hi Jim, I have heard that WPS does cover it, but you have to go through things sometimes to get them to say yes. Do not be discouraged by what a customer service rep tells you on the phone!!!! I do NOT have WPS, but I have Unity HMO Ins. here in Dane County. I have been through months and months of dealing with them and going through their processes to get approved. Even if there is a written exclusion in your new policy that says they won't cover wls you can still try. Let me explain. I have many comorbidities including severe reflux disease. The doctor I see for this referred me to a bariatric surgeon, as I am also in need of weight loss to control my other health problems. The surgeon wrote to Unity and asked for apporval to do a Roux-En Y gastric bypass for the reflux disease. Unity came back and said that gastric bypass was not the "standard" of care for reflux disease and they also felt it was not medically necessary. From that point on we began the appeals process. Most insurance companies have some type of procedure in place to allow you to ask for further consideration. You can find this information in your policy booklet. The surgeon wrote another letter, including documentation regarding studies that have shown that gastric bypass is a proven way to eliminate reflux disease. Unity denied again and I hired an attorney. With one appeal left I felt it was time to ask for professional help to do my last bidding! We did a telephonic call between myself, the reconsideration committee at Unity and my attorney. Unity denied again for the very same reasons. In the state of Wisconsin there is a law in place that allows you to have your case reviewed by an Independent Review Organization (IRO) if you cannot come to agreement with your insurance company. YOUR SERVICES MUST BE DEINED FOR MEDICAL NECESSITY OR FOR EXPERIMENTAL TREATMENT..these are the only two ways you can use the IROs. The IROs are contracted through the Insurance Commissioner's office and are not associated with any insurance company. Currently there are four different IRO's that you can use. I requested that my case be sent to one through Unity, they then submitted all the medical information they used to make their decision along with a $25 fee from me. On October 15th I received written information from the IRO that they overturned Unity's denial. My surgery is 12/16/03 and Unity is paying for it. All I can say is that it took me nine months, excellent documentation from my surgeon and a lot of hard work and endless letter writing and phone calls, but it paid off. Don't give up Jim and keep trying and using every angle that you can. In my own heart I knew that I had to take this as far as I could and exhasut every avenue. There is NO reason for any insurance company to deny you this life saving surgery! Go for it! Chris

You go girl!! You are awesome for not giving up. I will never pay an insurance company when I know they should pay. Congratulations on your weight loss success too! Have a wonderful holiday.