JUST BESIDE MYSELF !!!!

Well here goes.................I started this process in earnest the beginning of August 2005, tests,appointments,etc like everyone does. Long story short Dr Blackstone's office submits my stuff to the insurance company for review 12/30/05. Happy New Year! I am told the review process will probably take about 30 days. Last week I call the office to see if they heard anything yet ....and they hadn't. I call the INSURANCE company to see what the status is and get the run around..... finally I am told the request was NEVER RECEIVED. 30 DAYS OF NOTHING !!!!! I ask to speakto someone in prior auth to find out to resubmit and get nothing but attitude. I get a number and call the doctor's office back and ask them to resubmit which they do while I am on the phone. I call back later the next day to verify receipt of my records and "they didn't receive it". The office staff refaxes a THIRD time and I call back this past Monday to check. I asked for the name of the case manager because of all the screw ups and had some questions about the time this would take. I call the "case Manager" two days in row and get no response and get a response via phone from yet someone else. I explain what happened and why I called. Friday my file ended up on the desk of the doctor who approves or denies and he is questioning the notes of the doctor who did my medically supervised weight loss program. The billing person at Blackstone's office says this is the FIRST time someone with MY insurance has had this problem. COUNTLESS others have been rubberstamped through on my insurace plan. She thinks someone there is teed off at me for checking up on them. My response is that I NEVER would've needed to if things had been handled right the FIRST TIME and not wasted 30 days! I feel like I have been profiled here! Being a minority I KNOW WHAT IT IS. Anyhow, Monday the medical director and Blackstone's gang are having a "peer review" and I'll have an idea which way this will go. If I am denied they will SEE what "teed off" looks like! We'll see what happens. Has anyone else been where I am now with this and what did you do? Thanks, Kathy

Kathy, I worked for Dr. Terry Simpson in his Bariatric area. The good news hopefully for you is that every time "we" did a peer review the insurance approved the surgery. Often there is a "vague" area that the insurance folks may have been directed by their superiors to check on. Dr. Blackstone will possibly need to change some coding to comply with their requirements or simply clarify some chart notes. Hang Tight! Take the waiting period to study up on lifestyle changes following WLS. I would suggest the graduate sites to lurk and learn. You can not participate in the posting until you are 1 year post-op but there is nothing like the education of the experts who have been there and done that! Good luck! I seriously doubt that the minority issue is in play here. If anything, your persistence may have just drawn a bit of attention to a detailed reading of your chart. But, the squeeky wheel usually gets the oil! I'll bet you'll get your surgery before you now it! Joyce

Oh wow. This is insane!! A similar thing happened to me during the approval process. However the problem wasn't with Aetna it was with the dimwit insurance clerk at Dr. Fang's office who faxed them 3 yrs of medical records - even though I had given her SEVEN years of medical records at my office visit. She "got confused" because some insurance companies require 3 years some 5 years. After a few phone calls back and forth she agreed to do the appeal since it was HER fault I was denied. Well she sends the appeal and I wait. And wait . And wait . Turns out, like you, Aetna never received it. I verified the address she sent it to and turns out the address she sent it to was the DENTAL CLAIMS office. So I ended up going to Dr. Fang's office to pick up my records and I faxed it to Aetna to appeal and I got approved the next day. So I've been there dealing with people who don't seem to care or understand how important this is. That is messed up to wait 30 days and nothing was even done in 30 days. My gosh! How horrific!!!!!! Peer reviews usually result in approvals, so I wouldn't worry none. Easier said than done, I know. But hang in there. At least they have it now and it's not just sitting in a stack somewhere. And insurance companies are USED to patients calling in to check on the status of their claims/pre-auths. So don't feel bad for doing that because we all have done it and they are used to that. Everything happens for a reason, and although we don't always know WHY, everything turns out for the best because of it. So hang in there!! We are rooting for you 100%!! Keep us posted! Trisha

Thanks to both of you! Making the firm resolution to do this has been a HUGE step and I am ready to do what it takes. The idea of lurking on grad sites is super! The surgery will truly be the beginning.... Still no news about the peer review yet. The insurance did call me today and faxed me their checklist. I have a name of a clinical rep, phone and fax number. So I wait PATIENTLY(not so patiently) to see what is next. Thiis board is so supportive of one another. I will keep you posted. Thanks, Kathy