Insurance Information

Hello, I'm new to this site and forum.  I'm currently in the beginning processes of getting the surgery approved for myself.  I'm excited about the possibility of having the surgery and getting healthy again. Up until my recent move to Nashville, I was in the Benefits Administration business for over 20 years.  I wanted to give some insight to everyone concerning what can be covered or not covered under a plan.  You can take it for what is worth.  You can also email me or reply and I'll try to help as best as I can. There are many different types of benefit administrators and types of insurance.  Most large companies and quite a few smaller companies (100 or more employees) are self-insured.  They hire either large companies such as Humana, Aetna, BCBS, or UHC to administer the health plan that they have created.  The money used to pay claims is supplied from premiums and the companies own insurance fund.  The insurance companies or Third Party Administrators(TPA) are paid a per employee per month fee to administer the plan.  They don't get a bonus or anything else for denying a persons coverage.  These type of plans are governed by ERISA.  There is specific guidelines that must be followed regarding approvals, denials, and appeals of benefits.  You can find ERISA guidelines in the back of your plan booklet.  You can also go to your HR Department to discuss the benefits in these type of plans. If a Self Insured Plan governed by ERISA  has specific language excluding coverage for Obesity related surgery, they aren't going to cover it regardless of medical necessity.  Many insurance consultants design the plans to excluse this type of surgery due to costs to the plan.  I don't want to get peoples hopes up that medical necessity will override a plan exclusion because I've never seen it done unless the employer specifically asks for an override to pay for the procedure.  Most self insured plans have secondary insurance policies called stoploss coverage that kicks in at a deductible level usually in the 50K to 200K range.  Once an individual person on the plan hits that mark in paid benefits the insurance coverage kicks in and the company no longer has to foot the bill on benefit payments for that particular individual.  These policies aren't going to pay for benefits that are originally excluded from the plan so companies are going to be very hesitant to approve a procedure that could end up costing their company a million dollars if there are complications. (I've seen bypass claims with complications cost this much).  ERISA plans are also not subject to many of the state regulations on insurance so double check before you appeal using a state law.  Simply ask your HR Department if the plan is self insured and subject to ERISA.  Your plan document should also have this info in it. Fully Insured plans are a different ballgame.  They are simply plans that the employer pays a set premium and doesn't really have a say in what benefits are in the plan or how they are paid.  Generally these plans are canned type plans.  They are also subject fully to state laws.  You need to know your state laws and they can be found on the state internet page in most cases. They are generally administered by the BUCA's (Blue Cross, United Healthcare, Cigna, Aetna).  You can also put Humana and other large companies in this group. (Remember they can also be just an administrator for a self insured plan so check with your employer).   In these cases it is to the advantage of the administrator to hold down costs so that the premiums collected far outweigh the benefits paid thereby created a profit center.  They should have specific guidelines about the surgery in their plan document as to whether it is covered or not and what the specific guidelines for approval are.  Even with this said,  I don't think there is rampant denial of claims to keep profits up.  Each of these companies have armies of claim analysts who interpret the benefits as best they can.  Like any other profession they have good ones and not so good analysts so don't be afraid to ask questions and keep notes of who you speak with and what was said to you for future use.  With fully insured plans you do have the ability to file complaints to the Insurance Commission.  Like anything else the more documentation that you have the better off you will be in the long run.  If a plan document is not specific in what is covered vs what is not covered courts have shown that they generally rule in favor of the patient.   I hope this information is useful for everyone.  It isn't much but I'd be happy to help anyone I can.  Like I said earlier, I'm in the beginnning processes of getting my approval through UHC.  My plan is a self insured plan that specifically covers this procedure so I'm confident that I won't have too many roadblocks.  I'll keep you posted.  I'm looking forward to participating in this site and giving and receiving encouragement and help along the way.

 

 

 

Good to know. I have UHC, as well, but they set a $5000 maximum lifetime benefit on the surgery. I'll never be able to afford the remainder.

Could you help me we had UHC and were fully funded. There was an exclusion and they would not cover.  Now my company is going with Antheim Bc/Bs of Missouri- Blue Access choice PPO.  The broker said that we have to do the appeal process that all insurance is that way.  They said we will never be a self funded.  Do you think there is a chance.  This comes into effect Nov.1.  There is any exclusion, but the broker say that they are all that way.  Please Help.

I will try.  Being fully funded isn't a bad thing.  You will have to get a copy of the new plan doc provided by bcbs and look for coverage under obesity or morbid obesity.  I would think that all bcbs plans would have some language regarding this in the covered services or exclusions area.   Sometimes the exclusion shows that they don't cover services for obesity but do cover surgical services for morbid obesity.  Once you have the document you will be able to see how they treat obesity.  If the plan document is silent on the issue, I would think you would have a good shot at getting it as it would be medically necessary. Let me know what the document says about it and we can go from there.

Hi, George, Always glad to see an insurance pro!  Congratulations on your decision, and you probably have most of the battle won with your insurance expertise.  Wondering if you know anything about Tricare (HMO), which is also Humana Military.  They exclude CPT 43845 currently, but I found an update to the Policy Manual which lists DS as a code that has moved from "unproven" to "proven" and is appealable for reconsideration through the appeal process, after Jan. 1, 2005.  However, I can't find anyone on OH or anywhere else that has been able to get DS approved on appeal with Tricare (even though Medicare cover it now).  Many have tried.  Do you have any knowledge or suggestions? Also, they have an insurance board that these posts would be really helpful to.  I've notice old habits die hard, and everyone wants to keep posting all subjects here on the DS board.  Hope the Insurance message board gets going, since that's the biggest battle for most us besides the weight!

You would need to somehow get a copy of the "new criteria" that they are using to formulate whether it is considered medically necessary.   I'm new to the site so I didn't know there was another portion of the message boards that deals with insurance as well. I found this on Tricares website under patients bill of rights. I hope this may help you with your appeal process.  Victor Presidential Memorandum February 20, 1998 "Federal Agency Compliance with the Patient Bill of Rights" (d) Chapter 55 of title 10, United States Code 4.7.1. When healthcare services are denied by an MTF (which will neither provide nor authorize TRICARE payment for) or a TRICARE contractor (which will not authorize TRICARE payment for) based on a determination that the services are not medically necessary (including experimental or investigational), the beneficiary has the right to internal and external appeals. 4.7.2. Internal appeals subject to subparagraph 4.7.1., above, shall follow reconsideration procedures consistent with 32 CFR 199.15 (f) through (h) (reference (e)) for the TRICARE Quality and Utilization Review Peer Review Organization Program. This shall include written notification of the decision, the reasons for the decision, and appeal procedures; timely resolution, including special emergency time standards, use of credentialed providers not involved in the initial decision; and written notification of the reconsideration decision, the reasons for it, and the external appeal procedure 4.7.3. External appeals subject to subparagraph 4.7.1., above, shall follow the procedures established pursuant to Section 199.15 (f) through (i) of reference (e), including reconsideration by the independent National Quality Monitoring Contractor (NQMC) and appeals and hearing before the TRICARE Management Activity. NQMC procedures shall require determinations by appropriately credentialed specialty providers not involved in the initial decision, timely resolution, and emergency time frames consistent with Medicare's appeal process. 4.7.4. Beneficiaries with grievances about specific treatment or coverage decisions other than those covered by subparagraph 4.7.1., above, shall have an opportunity to seek resolution through the MTF or TRICARE contractor involved through procedures widely disseminated to beneficiaries.  Chapter No. 13 - Appealing Certain TRICARE Decisions

Appealing Certain TRICARE Decisions

 

If you have a dispute with certain decisions made by a TRICARE contractor or by the TRICARE Management Activity (TMA)— formerly known as the TRICARE Support Office, and as CHAMPUS headquarters, or OCHAMPUS—you have the right to ask the TRICARE contractor or TMA to take another look or to get another opinion on the decision.

IMPORTANT NOTE: This chapter describes the TRICARE appeals procedures applicable to the routine processing of TRICARE claims and authorizations for care, and health care provider sanctions, by TRICARE contractors and TMA. However, TRICARE “demonstration” projects and special programs may be in place that alter the appeal procedures described in this chapter. Whatever the situation, a decision that is appealable should include notice of your right to appeal, including the address of the next level of appeal. If you have any questions about your right to appeal after reading this chapter and the specific notice of your appeal rights included on a TRICARE decision, check with your nearest BCAC/HBA/ TSC, or the TRICARE contractor for your region, for more information.

The appeal process varies, depending on whether the denial of benefits involves a medical-necessity determination, a factual determination, or a provider sanction. All initial and appeal denial determinations include a section that fully explains how, where, and by when you must file the next level of appeal.

Medical-necessity determinations are based solely on the following:

• Whether the care was medically necessary.

• Whether the level of care was appropriate.

• Whether the care was custodial. Or—

• Other reasons related to reasonableness, necessity or appropriateness.

Generally, determinations relating to mental health benefits are considered medical-necessity determinations.

The appeal process for adverse medical-necessity determinations is as follows:

1. A reconsideration, conducted by the TRICARE contractor for your region.

2. A second reconsideration, conducted by an independent contractor called the National Quality Monitoring Contractor (NQMC).

3. If services have been provided, a hearing administered by the TMA Office of Appeals and Hearings, and conducted by an independent hearing officer.

Factual determinations are rendered in cases involving issues other than medical necessity. Examples of factual determinations are those involving the following:

• Coverage issues (that is, whether a service is covered under TRICARE policy or regulation).

• Hospice care.

• The Extended Care Health Option (formerly Program for Persons with Disabilities)

• Foreign claims.

• A mix of both medical-necessity and factual-determination issues.

• Denial of a provider’s request for approval as a TRICAREauthorized provider.

The appeal process for adverse factual determinations is:

1. A reconsideration, conducted by the TRICARE contractor for your region.

2. A formal review conducted by the TMA Office of Appeals and Hearings.

3. If services have been provided, a hearing administered by the TMA Office of Appeals and Hearings and conducted by an independent hearing officer.

My company is one of those large self insured companies that has a policy overseen by Cigna.  It's a POS plan.  WLS is excluded.  I called my benefits department and was told that they would call CIgna and "flag" my attempt.  They have paid for all my testing, cardiac stress test, abd. ultrasound, chest xrays, full pulmonary test, the works.  They have also paid my surgeons initial visit. They tell me in my benefits department that if the insurance company says it's medically neccessary, it wil go before a "board" to be voted on as to whether it will be paid for or not.   Have you heard of this before? Thanks for your posting!

Many self-insured companies will consider making an exception to their plan language from time to time, using their health benefits appointed "board" to determine whether they want to make an exception to a plan exclusion.  However, these can be very random at best.   I'm not sure how large the company is or what the risk to them would be if they covered the procedure.  If they have a reinsurance policy with an insurance carrier (insurance for amounts over a certain dollar limit spend per individual), it would be a risk to them if complications occur because they approved a  procedure that would not be covered by the secondary carrier so their dollar exposure could be significant.   I wish I could be more specific but they fact that they are even considering it when it is specifically excluded is a positive step.   Hope this helps.  Victor

Hi!  And thanks so much for sharing your experience. I have a question I am hoping you can help me with.  I was reading my company's certificate of insurance, and it contains an exclusion for "weight reduction or treatment of obesity."   Does this typically also include surgical treatment of morbid obesity?  I have a call into my HR department, but I'm on pins and needles waiting for an answer. Thanks Maureen