So frustrated with insurance

I verified with my isurance that the DS would be covered under my policy. They said yes as long as the doctors submitted the paperwork for prior authorization. I verified that Dr Roslin was in network, they gave me the amount out of pocket I would have to pay...ok I'm all set to get started with the seminar. I pay to take the trip into the city on Amtrak and incur other fees associated with traveling in the city as well. It went great (actually met with Dr Teixeira but got great information). Got back home and called insurance to verify I didn't need a 6month supervised diet that the seminar said might be required. Insurance said nope, that's not necessary but by the way, you can only have bariatric surgery at the hospital you work at. WHAT?! So I go back and forth about miscommunication and how I don't trust just any surgeon to perform this complicated procedure. They say there's nothing they can do. I call my hospital just to slightly entertain the thought of getting it done there and when I ask do they perform the duodenal switch, they replied, that they only do bariatric surgery here. WHAT?! So I go on to explain the DS is in fact a bariatric procedure to which they replied they never heard of it only do the lap band sleeve and bypass. I'm in utter state of confusion as to how a bariatric center of excellence can not be familiar with the duodenal switch, even if they don't perform it. Even more validation of not getting surgery there. So I call my insurance back and inform them that the hospital doesn't do the DS, and they state well you can only have WLS there. So bottoms line, I can only have bariatric surgery at my hospital and even though they don't perform this surgery, it won't be covered elsewhere, even for in network providers. Dumbest thing I ever heard.

first what you were told is incorrect information. they cant force you to have a surgery you don't want, in essence that's battery. if your medical professions have stated that Ds is the best surgery for you, they have to let you go out of network, it is not your fault that they don't have anyone in network or at that dumb hospital to perform that surgery. While the Ds is performed

While the Ds is performed

for some reason the rest of my message keeps getting cut off

While the Ds is performed less than1% of all total bariatric surgeries, it is performed. even if that hospital knows about that surgery which they may or may not they aren't going to send you out, its about money.

you have to appeal, forget about talking to them on the phone, get your evidence of coverage, know it from the start to the end, especially the exclusions which have to be stated for a lay person to read and understand. they must also not be hidden and plain. what does it say for the HMO, about your PCP, what is considered in network. see all insurance companies let you go out of network, example....transplant patients, the insurance co knows they have to go out of network, that is allowed because it is in the best interest of the patient, and most places transplants are not performed, LIKE the DS, and IT DOESNT matter, they have to allow you to go out of network. I have a HMO also, I've been down that road many times. I have been out of my HMO network for 7 of my 21 surgeries. going up against the big bad insurance company is not for the faint of heart. if you cant do it, get an attorney.

I got the rest of my message in :)

Thank you do much for this information! The insurance company definitely made it seem like that was the last word but I will contact the surgeons office and see what they can do as far as appeals. It just doesn't make sense to me that I can't get the procedure done elsewhere since the preferred hospital doesn't this particular surgery. The doctor is in network so it should be an exception. I will update this post if anything comes of it.

Even if the doctor is out of network, if you have the coverage and there is no in-network surgeon who does the operaiton, they can be forced to cover it with the out of network surgeon.

Never, ever, rely on what some random insurance (or even HR) employee tells you over the phone. Get your EOC (evidence of coverage) a long document, like maybe 100 pages, NOT just a little summary of benefits. If the person you speak with in HR has no idea what you are talking about (which happens all the time), go up the food chain until you get someone who does. This document should also tell you about your appeals rights, which is important because you probably have a fight ahead of you. Remember, your insurer's concern is not your health and welfare, it's to make money, or at least spend as little as possible.

This would also be a good time for you to start documenting everything - save all correspondence and email. Keep a record of every phone call - name, job title, phone number, date, time, and brief summary of conversation. You never know when you may need this.

Larra

I had a policy that only covered one hospital. I needed back surgery and my surgeon agreed to do the procedure at the hospital where I was covered.

If you can find a DS surgeon who is willing to do the surgery at your hospital then it will be covered as long as that surgeon is also in the network for your insurance.

My surgeon was in the network, but preferred to operate at another hospital. The two hospitals are only one mile apart.

My policy would have covered a surgery at another hospital in a life-threatening emergency.

Your choices come down to finding a DS surgeon in your network who is willing to perform surgery at your hospital, or changing to one of the weight loss surgeries that is performed at your facility.

Aside from the other information people gave you it might be of consequence that your hospital doesn't perform the surgery that you want. It's possible the insurance guy didn't understand that and considering the hospital response not surprising.

I can see the logic where they want you to have the surgery at your hospital. I imagine they do accounting tricks so the cost is lower but that supposes that they actually do the surgery that you want.

Fight it.

Good luck,

Pete

an update...

I had my first appt with Dr Roslin. He proposed going forth with the modified DS. I was going to have an upper GI the same day to evaluate my sleeve but the radiology dept didn't have any barium! So I have scheduled that at my primary hospital. Next steps include psych and nutrition consults. There will be a fight with my insurance but I will continue to update this thread. Hoping for a smooth appeals process!