Help Needed. Medical Mutual of Ohio Denials WTH???

At initial visit back in September the center contacted my insurance for coverage, which I had. Insurance approved my surgery. Received approval letter from the insurance and the center also received approval. I met all the requirements, ect. If not, I would not have surgery and insurance would have denied. Surgery was Dec 22, 2016. 

I checked today on my insurance on-line and it was coded "014", meaning obesity is not a covered service. WTH???

Over $34k+ denied??  I am freaking out and had to take a Xanax. They denied my initial visit with the surgeon for "obesity", another $300. Double freaking out now. Checked my blood pressure and it is up. All other doc visits were approved and paid for as well as stress test and heart cath. 

The business manager at the practice is wonderful and very nice to me but when I call her on Monday, I hate to see her reaction. I know she works very hard. Medical Mutual is actually making me very ill now and this is completely uncalled for. 

My friend at work had same surgery (sleeve) and same insurance and they paid everything but she did have small deductible. Her's was in November. I met mine and out of pocket as well for 2016. I just don't understand. 

Also, other bills were denied such as blood tests (October) and readings ox x-rays (November) from my stress test. 

Please someone tell me what to do as I am very upset now. 

Take notes when you call them on Monday and be prepared to write letters. Make sure that your 2016 policy did not exclude obesity treatment. Your friend may have been covered by mistake if you have the exact same policy.

As long as you have your approval letter, you should be able to get things straightened out with the insurance.  Do you have your insurance requirements from 2016?  It is possible that you were covered last year and not this year.

Having your surgery at the end of the year, it may have been processed with 2017 requirements instead of 2016.  I think you will get everything resolved. 

I have experience in the insurance industry.   Insurance is tricky, but not just in the way the claim is paid, but how it is submitted.   The first step is to find out if the Sugeon got a pre-authorization or prior approval for the surgery, which you said they got.   This is done for ALL Weight Loss Surgery procedures and the physician's office must submit documentation of medical necessity in addition to any policy guidelines you have to meet (i.e. nutritional classes, dietitian consult, psy eval, etc)    So, they got that.   This authorization had to be reviewed by a Case Manager who would also look at your policy benefits to be sure it is a covered expense.  

I have worked on both sides of this, insurance company and a hospital/physician's office.   Insurance companies are not perfect and adjusters make mistakes.    Dr.'s are pretty thorough in getting what is required and the hospital would not have allowed you to be admitted without a prior auth and they do their own verification of eligibility and benefits, so my first inclination is that the insurance company is denying claims associated with your surgery because they need more information.   

Take a deep breath, don't overly stress about it.  I know that is easier said than done.   Even if they did deny it for obesity not being a covered item, your surgeon's office will do an appeal showing that they followed all the guidelines and were told it was a covered benefit at the time they inquired and submitted for prior approval.     

I hope this information has been helpful and given you a bit of relief.   

The Xanax has kicked in.  Besides me and my co-worker, several others at work with the same plan had this surgery. I'll call Monday. I called MMOH and spoke with someone ( she was nice) but as I have Mutual Health Services, (employer funded) a part of MMOH, she was able to look into the claim, but not in detail. She had a different claim number than was listed on the MHS website. She stated a bit over 5k was paid and I don't have a patient liability.  Not sure exactly if this pertained to the 34k, as it doesn't sound right. There were several claims submitted dated 12/22/16. I doubt 34k was discounted to 5k, does that sound right?  Other than this, I'll try to relax and may go see a movie. 

Paying 5K on 34K sounds correct.  If the hospital billed for 5K the insurance would pay them about $200.

It is all a game, but if 5K was paid for 12/22 then I am sure you have nothing to worry about.

A friend of mine, both she and her daughter had sleeve surgery 5-6 months apart. Same Doctor, Same Insurance policy.... Her daughter's went through no problem....her turn- after  pre-approval and surgery she got a Bill for like $80,000 .... she freaked...the office told her not to worry, they would take care of it and they did....

Oy. The office manager actually said MMOH was the easiest insurance company to deal with. Maybe to medical offices but not their patients. Thank God for Xanax. 

Take a deeeeeep breath. It could be that they have coded the services incorrectly. If you have an approval letter - stop panicking. It will be fine.

Call your insurance company on Monday and talk with them. Give them the denial code and date of approval letter.

No need in making yourself sick over this. Mistakes happen with computers....and with people.

Sending you good thoughts.

Thanks. I'll call Monday. I'm totally relaxed now.