INSURANCE TROUBLES

Hello All

 I could use some advice and some support.

  I was approved for lap band surgery with Highmark bcbs from penn. After a 6 month supervised diet a physch evaluation and several other hoops' do to my health. But they finally approved me in June to have the Surgery, But my employer switched Insurance co in July to a company that will not cover it. Anthem bcbs of Ohio. They say they have a Written exclusion and there is nothing I can do. I was told in june by our Insurance broker in June that the coverage we were swiching to was the same but as you can see its not.

I spoke to my employer and they said its not there exclusion its anthem becuase we don't have a 100 employees at this branch.
I talked to Anthem and they said since its an exclution that there is no appeals process, this sounds like a lot of double talk is there anyway around this
please help

Thanks
TM

Unfortunately...probably not. Insurance companies can and will refuse WLS coverage to employers with fewer than 100 employees and individuals.

Some states are enacting laws to prevent this. At this time, your state allows it.

Frankly, I wouldn't be surprized if your original insurance made you "jump through hoops" on purpose to stall you until the coverage expired.

Larissa, insurance reviewers have no idea when a group is going to cancel or go to another coverage.  Working in the industry for 30 years in the review area we were there only to review for medical necessity we did not have the components to review enrollment and billing so I don't think it was a stall,   I am no way defending what insurance com panies do for employers with less than so many employees I think its wrong but was just wanting people to know that your comment is not necessarily true

I need help. My hospital submited the incorrect BMI for me and my insurance company denied my original pre-determination. I have appealed the it and was advised they do now see that my currect BMI is over 40..but now they are requesting a 5 year history of obesity which I have. I submitted that to the insurance company and Monday is the deadline date for their decision. I do already have a scheduled surgery date but is was given to me only because the hospital made such a huge mistake..so if my approval does not come in on Monday then they ae taking me off the schedule. The only issue that I am having is that the 5 year history is from one doctor that I attended a weight management program through off and on for about 9 years. All his notes and files are all hand written. Is that going to be a probolem? I am honestly looking for some good news right now?

If you have the five years of history showing your obesity then whether its hand written by the doctor or dictated the review area are capable of reading handwritten notes,  reviewers in the medical review area have to have at least the bare min. of at least a LPN degree but most are RN's or MD depending on what level review they are reviewing at.   I dont see it as a problem for you.  The hospital should be doing flips for you to the insurance since they made the terrible mistake probably a typo but still an error is an error.

V icki

Of course not a problem will be glad to assist you in writing up an appeal.  Think positive that you will be approved though

You are so right. I will think positive and hope for the best. I can't let myslef get down about this. I appreciate your support. I will keep you posted. Thanks again.

Vicki,
They denied me today. The only thing is I have no real idea why. I was on the phone with them for 2 hours and just being transferred from one person to the next. Can you please help me? What number can I reach you at?

Did they give you a reason for denial?   We need to wait for the denial letter to come so I know what where dealing with as far as denial and go from there

I wi**** was just a typo. They submitted a BMI for me that was over a year old. Instead of my current BMI for the last 5 months when I was meeting with surgeon and go through the entire pre-surgery process. You have no idea how frustrating this whole thing has been for me. I wasn't concerned with their ability to read them. I was more concerned with them wanting addditional information. Because the file was literally just the date and what was weight was on that date. Nothing more really. But it was stamped by the doctor with my name and birth date on every page. Since tomorrow is the deadline date, god for bid but if they do deny me, which you mind if I contacted you for assistance on my next appeal. I am pretty determined.