Insurance denial

I have a question that I hope someone can help me out with.  I was going to wait for my Ins. to call back but they do not answer the phone and the message I get is that they will be able to return my call in “24-48 business hours.”  Yes, it usually takes the six days to hear back from them and you do not want to miss the call and start all over.  Anyways...   My question is:  After my second appeal my surgery has again been denied.  I want to know if there is some kind of waiting period before starting over and resubmitting another claim?  Do I go through a new surgeon or new doctor? I think I honestly need to find another surgeon.  I love him to death but his office help sent my information off to the insurance company incomplete.  I was denied of course within days.  The office worker called and told me I was denied and that she would not help me to appeal anything.  I've been winging this the entire way.  I have all my information, everything that the insurance company wants.  It was just all sent to them all scattered about because of the first initial approval request.  I have the diet history, doctor supervised, nutritionist visits, weight loss history, psychologist approval, letters from Dr., psych, nutritionist, PFT, ECG, conditions.  I just look like mentally handicapped because it's all random.

 

 

 

I just want to cry.  I don’t know what to look forward to, and now My last chance is through a hearing.  I need some kind of patient advocate or something.    I left a message from the insurance company to call me back and I know when she calls I'm going to have some kind of messed up break down.

If it is possible for you to go to pheonix for a surgeon. Then I recomend dr.villeres. It is at the banner good samaritan bariatric center. I know you dont want to hear this, but I was apporved the next day! I honestly love his staff and they get us in and out. They tell us everything you need to do! Let me know if you need anything, even just a friend.

I have been going to Phoenix to see Dr. Fang.  I've gone to all the seminars and did everything he required.  I've spent almost two years working toward this.  I really didn't think I would be approved  (I don't like to get my hopes up before I know the overall outcome.)  Whenever the insurance asked me for a test I would ask the representative if he thought I was going to be approved and he always said yes.  I didn't want to go through more tests and more money if he knew that I wasn't going to be approved.  So I completed the tests, and did what both the INS and surgeon's office suggested.  When I got the letter of denial today it was just messed up and I'm so upset about it.   I totally blame myself.  I'm mad at myself!  I'm also mad at the person who was supposed to help me at the surgeon’s office. When I left Dr, Fangs office after my initial consultation I was completely confident that she was going to do everything that she could to help me.  A little communication between the doctor’s office and patients would have been great.   I don’t know why my info was sent out incomplete.  I don’t know if she made a mistake.  The only information she gives me is that I was denied and it is no longer in her hands.  They will not do appeals because they “get dirty” as she put it.   I don't know where anything stands anymore and I don't even know what the best route is to take with the second denial.  I can call Dr. Villares office in the morning.  Maybe they can give me an idea on how to work through this. 

 

 

 

 

 

Thank you for the reply!

You might try talking to an office manager, of even the doctor himself. If it is the office staffs fault and they did the paperwork wrong they should resubmit it for you. That would upset me also. I've noticed people tend to blow off customers or patients with a generic answer without even looking at the problem which in this case in "no we won't appeal for you" ; however if she were forced to open her eyes and see the mistake is hers her answer might be different. It is a shame to spend that money and then have to transfer. Then again, if your getting this treatment already it may be a good sign to count your losses and get out while you can.

P.S. Karen, Having worked in the industry for quite a while, I know that some insurance companies just deny the first time no matter what.  .....  You can and SHOULD appeal if you meet every bit of insurance criteria!!!! Call Kelly at Bridges if the staff isn't working in your behalf.  She will take care of you!

Ya, I’ve thought about that.  The office manager there is Jennifer.  I talked with my insurance representative and I explained to him what had happened.  He told me about my denial and that I still needed to have two further tests ran, ECG & PFT.

I then scheduled the tests but the tests dates put me over on my deadline for appeals so I called the INS. back and he told me that the surgeon’s office would have to resubmit my information if I couldn’t get the tests done in time for the appeals deadline.

So I call my surgeon’s office to tell her that my Ins. Co. wanted her to resubmit the info after the tests were complete.  She told me no and that her advice for me was to send in all the information I had by the deadline and then wait to be denied again.  Then that denial would give me the extra time to get the tests done so that I could send in another appeals with the ECG & PFT results.   My deadline was so close by this time that I knew that my INS. Rep. would not be getting back with me in the time allotted in his message (24-48 business hours for a reply.)  I took her advice and sent in the diet history and proof of weight loss, (the two items that the she did not include with the very first submission.) 

I then called my INS. Rep. to explain why I sent in the info the way I did.  He couldn’t understand why she would not appeal for me but said he would call and require her to further appeal.  It was then when I asked him if I was going to be approved after all these back and forth actions were over.  He reaffirmed that all I needed was the tests and that I would be approved.  I then asked if when I received the test results if I should send them to him at the insurance co. and he said no to send them to the surgeon’s office and when he had her appeal she would have the information for the appeals.  So that’s exactly what I did.  I sent the test results to the surgeon’s office last week.  Now I have my second denial with several different codes in the letter that I can’t find the meanings to anywhere and the statement of “Our final decision is to deny this appeal”.  I can, however, request a formal hearing.  I forgot to mention that the INS. Rep. I’ve been speaking to is now on vacation until the middle of June.  That was on his message today when I called. 

 

So I figure that this is all just a test.  Am I a strong enough person to keep going back and forth and waiting the days being sure not to miss that call from the INS Rep., and then calling my surgeon’s office in hopes for some kind of support.  By the way I have only received one call from her and it was to let me know that the INS denied me.  

 

All I read on here is good things about my surgeon’s office clerk.  I honestly think I just kind of slipped through the cracks somehow.  I think my info was sent out by mistake.  I would like to think that this is how it happened but then to have her not even attempt at helping me with an appeal and being so blatantly rude about the situation has really made me want to start over and find better support.  She really put off the persona that, it was not her problem. I am going to make some calls in the morning and try one more time with Dr. Fang's office.  I am still going to call and get advice from others the best I can also.  

Karen, You have another shot at this with he same program.  They MUST tdo a Peer REview for you.  That's when  your surgeon actually talks to the medical specialist with your insurance and points out all of the facts and also points out their mistake in sending it all in stages! Going to another surgeon will not change anything with your insurance unless they are a lot more aggressive and can dig up more facts. Don't give up!  You've got a reward just aound the corner!

You’re so right! I totally forgot about Kelly.  Dr. Maxwell did a follow up call and referred me to Jennifer.   I think have a lot of phone calls to make today.  I do have a fair hearing still left and my INS co. called this morning!  I just called her last night.  WOW! She let me know that the Dr. office would not reapply but it was nice that they did attempt to get them to do so.  My INS person also let me know that I can completely start over at anytime which is a bummer to do so but at least the option is there.  I guess after I make the phone calls today I will start my next letter requesting a hearing.  

 

When would the peer review normally happen? 

Hi Karen- Hang in there. You have all the pieces - you just have to put them together. I speak from experience. My journey through denials, "walk-aways" (mine), and appeals took 3 years, but I have been approved and am scheduled for surgery.  I hasten to assure you that this will not take you 3 years! I made some poor decisions  - each time I was denied, I was so discouraged, I "walked away", thinking it would never happen, and that I would never be approved. The insurance company is a clever entity - the letters of denial were always somewhat convoluted and it was difficult to get to the heart of the reasons for denial - the one thing I always understood was that I would never, ever, meet the criteria and be approved. Silly me! That was what they wanted.  Every time I called the insurance company, I got a different person who told me a different thing. At no time did I feel there was an insurance rep advocating for me. And for a while, the doctor’s office had kind of written me off too. Let’s face it – if the insurance company (and, in my case, my self-insured employer) does their darndest to ensure that no one is approved for this surgery, it’s pretty daunting to the doctor’s office too.  And they have lots of patients wanting the surgery, who might be more easily approved.

 

By the way – I am a State of Arizona employer, insured by UHC. I believe all the insurance companies for the State have the same criteria – they are all “3^rd party administrators” of the State insurance plan. See? More gibberish that makes it harder to know who to contact and how to approach the problem.  Eventually, once the doc

 

 

I think one of the things you have to do is approach someone else in your doctor’s office.  It is true that the doctor’s office cannot handle your appeal. Early on, my dr’s office did some of the paperwork, but I believe it ultimately became kind of a conflict of interest – the appeal is up to you.  You can do it yourself, or you can hire someone to help you with it. I did that, but in the end, I realized that I could have done it myself or – if you really need help, there are plenty of people on the boards here with lots to offer.  They all advise one thing first – get a copy of YOUR INSURANCE COMPANY’S CRITERIA.  

 

Here are 2 links to threads with a lot of good information – and there are plenty of others. http://www.obesityhelp.com/forums/AZ/a,messageboard/action,r eplies/board_id,4805/cat_id,4405/topic_id,3300282/page,1/#25 540233

 

 

http://www.obesityhelp.com/forums/AZ/a,messageboard/action,r eplies/board_id,4805/cat_id,4405/topic_id,3294523/

 

 

The main thing is don’t give up!  It seems overwhelming, and I let that deter me, which was my big problem.  Sit down with a checklist of what you need and what you have, and get it organized for your appeal.  remember that a new “notification” insurance-speak for request for authorization) worked for me after my appeals were exhausted. There is plenty of help and support and encouragement for you on this site. Just hang in there.

 

Thank you all so much for the information. I did call Kelly.  She said that she really didn't have much experience with the INS companies.  She did say that I seemed to be right on track and I should call Jennifer at the surgeon’s office.  I called and left her a message and hopefully I can get her to resubmit my information to the INS Co.  I really don't want to go through a hearing.  I don't know what to even expect. I did ask Kelly if they possibly had a patient advocate that could help me with the process and she said no.  I wish they did.  It's all I've heard about since starting nursing school.  PATIENT ADVOCACY!  Is there such a thing?