Confused as to Aetna's requirements vs. my hospital's --If you have Aetna, I need your help
Hi all,
I had my first appt. today w/the psychologist at the hospital I've chosen for lap band. I have many many appointments set up for the next 3 months--nutritionist, physician, behavior modification group, etc. etc. The program is very comprehensive and is 3 months long.
Aetna, I know, has a 3-month and 6-month program. I've gone to the plan document and have even shown it to my doctor but I still don't understand if what AETNA wants is encompassed in this very involved hospital program or do I do this OUTSIDE of the hospital;'s program?
For example for those approved by Aetna, how did you 'prove' nutrionist visits? What about proof of exercise? Anything else. The plan document , while full of information, doesn't actually say HOW to get the requirements DONE. Member services at Aetna hasn't been any help.
WHat did you do? What can I do to ensure that I make the most of the next 3 months and have the best chance of getting approved?
Thank you so much in advance,
Michelle
I had my first appt. today w/the psychologist at the hospital I've chosen for lap band. I have many many appointments set up for the next 3 months--nutritionist, physician, behavior modification group, etc. etc. The program is very comprehensive and is 3 months long.
Aetna, I know, has a 3-month and 6-month program. I've gone to the plan document and have even shown it to my doctor but I still don't understand if what AETNA wants is encompassed in this very involved hospital program or do I do this OUTSIDE of the hospital;'s program?
For example for those approved by Aetna, how did you 'prove' nutrionist visits? What about proof of exercise? Anything else. The plan document , while full of information, doesn't actually say HOW to get the requirements DONE. Member services at Aetna hasn't been any help.
WHat did you do? What can I do to ensure that I make the most of the next 3 months and have the best chance of getting approved?
Thank you so much in advance,
Michelle
(deactivated member)
on 3/5/09 7:48 am - Woodbridge, VA
on 3/5/09 7:48 am - Woodbridge, VA
Your surgeon should have an insurance coordinator who can answer these questions. It sounds to me like the plan with the hospital is comprehensive enough to fulfill Aetna's 3-month requirement (I did the 6-month since I had a different insurance when I started the process and didn't switch to Aetna until I had just completed my 6-month diet).
As for how you "prove" appointments, every time you see someone, be it a doctor or a nut or a therapist or whatever, they should keep a record of your appointment including the time/date, what was discussed, and other pertinent info (like vitals from a doc, recommendations from a behavioral therapist, etc.). I do believe you need to see an exercise specialist as part of Aetna's 3-month program, but maybe your PCP could record your exercise plan? Again, I would think that's a question for your surgeon's insurance guru. You shouldn't have to figure out all the insurance stuff yourself.
As for how you "prove" appointments, every time you see someone, be it a doctor or a nut or a therapist or whatever, they should keep a record of your appointment including the time/date, what was discussed, and other pertinent info (like vitals from a doc, recommendations from a behavioral therapist, etc.). I do believe you need to see an exercise specialist as part of Aetna's 3-month program, but maybe your PCP could record your exercise plan? Again, I would think that's a question for your surgeon's insurance guru. You shouldn't have to figure out all the insurance stuff yourself.
Many of us had to do create our own regimen. That said, if your hospital has one that works - great!
I must admit that I was kind of shocked that my surgeon's office didn't really have any help to offer regarding the regimen. So I made separate specialist appointments and told each doctor or expert what I needed from them based on the Aetna policy guidelines. All the offices were cooperative as long as I was polite and taking the lead and doing some of the leg work. I had to insist on appointments in consecutive calendar months because nurses usually only think in days from last appointment. Aetna didn't really care if the appointments were 10 days or 50 days apart, as long as the calendar months were covered.
I would make sure that you see the dietician & PCP in each of 3 consecutive "calendar" months & see the shrink and a fitness expert at least once each. All of your specialists should be copying all their office notes to your PCP, and then your PCP can send ALL data to the surgeon's office after your 3 months are completed. You probably will have to sign a form to request that these offices and/or doctors can talk to each other. Don't assume that they will interact with each other unless you've already been told so specifically already.
My surgeon's office has their own shrink, so all my PCP had to send was a copy of the fitness plan, her own office notes, and office notes from the nut/dietician. Office notes need to include progress or lack of (including weigh-ins). My experience was that you'll need to get healthier but you don't have to lose weight during your regimen.
I must admit that I was kind of shocked that my surgeon's office didn't really have any help to offer regarding the regimen. So I made separate specialist appointments and told each doctor or expert what I needed from them based on the Aetna policy guidelines. All the offices were cooperative as long as I was polite and taking the lead and doing some of the leg work. I had to insist on appointments in consecutive calendar months because nurses usually only think in days from last appointment. Aetna didn't really care if the appointments were 10 days or 50 days apart, as long as the calendar months were covered.
I would make sure that you see the dietician & PCP in each of 3 consecutive "calendar" months & see the shrink and a fitness expert at least once each. All of your specialists should be copying all their office notes to your PCP, and then your PCP can send ALL data to the surgeon's office after your 3 months are completed. You probably will have to sign a form to request that these offices and/or doctors can talk to each other. Don't assume that they will interact with each other unless you've already been told so specifically already.
My surgeon's office has their own shrink, so all my PCP had to send was a copy of the fitness plan, her own office notes, and office notes from the nut/dietician. Office notes need to include progress or lack of (including weigh-ins). My experience was that you'll need to get healthier but you don't have to lose weight during your regimen.
Aetna's 3 month program is a 90 day surgical prepratory program. It must be 90 or more days, not 88, or you will be denied. The surgeon I used to work for did it at their office.
The patients met the nut every 30 days, discussed diet and exercise.
We submitted one form for each month. The form had your name and DOB, the diet program you were following and the exercise you were doing--that's it.
You also need a letter from your surgeon AFTER completion of the program---"Sally completed a 90 day comprehensive surgical prep program with our office. She has been educated on proper nutrition and exerise. She has been compliant with the program. I reccommend proceeding with RNY." You also need a letter from the nut (nut eval) and your psych, along with a weight from your old medical records for the last 2 years. Thats it!
If you have all those pieces, you will be fine! Aetna is easy if you have all of the above.
Good luck!
Bonnie
The patients met the nut every 30 days, discussed diet and exercise.
We submitted one form for each month. The form had your name and DOB, the diet program you were following and the exercise you were doing--that's it.
You also need a letter from your surgeon AFTER completion of the program---"Sally completed a 90 day comprehensive surgical prep program with our office. She has been educated on proper nutrition and exerise. She has been compliant with the program. I reccommend proceeding with RNY." You also need a letter from the nut (nut eval) and your psych, along with a weight from your old medical records for the last 2 years. Thats it!
If you have all those pieces, you will be fine! Aetna is easy if you have all of the above.
Good luck!
Bonnie
(deactivated member)
on 3/9/09 1:24 am - Woodbridge, VA
on 3/9/09 1:24 am - Woodbridge, VA
I just wanted to add that I've seen multiple Aetna members get approved without 90+ days in the program, just visits for each of 3 consecutive months, sometimes only 75 days or so. Maybe it just depends on the mood of the Aetna employee reviewing it that day!
Hi,
I was approved on Aetha's 3 month multidisciplinary program and my surgery is in two days!!
You need to make sure the appointments span over 90 days . I saw my PCP each month, my dietician each month, an exercise specialist. My PCP documented all of this and the dietician also documented each time I went and send those notes to my PCP.
Like Bonnie says in her post. I had my PCP write a letter stating I had started a 90 day multidisciplinary program, and then a second letter stating that I had completed the 90 day multidisciplinary program. She made sure to document 'behavior modification' in her letter and office notes, such as joining OH as an online support group, joining a local support group, and other behavior modifications.
Good luck. If you follow the requirments, Aetna will approve. I had no problems with Aetna, very nice to work with.
I was approved on Aetha's 3 month multidisciplinary program and my surgery is in two days!!
You need to make sure the appointments span over 90 days . I saw my PCP each month, my dietician each month, an exercise specialist. My PCP documented all of this and the dietician also documented each time I went and send those notes to my PCP.
Like Bonnie says in her post. I had my PCP write a letter stating I had started a 90 day multidisciplinary program, and then a second letter stating that I had completed the 90 day multidisciplinary program. She made sure to document 'behavior modification' in her letter and office notes, such as joining OH as an online support group, joining a local support group, and other behavior modifications.
Good luck. If you follow the requirments, Aetna will approve. I had no problems with Aetna, very nice to work with.
Nan
HW 300 / SW 280 / CW 138 / GW 140
Hit Goal 4/2/2010
I started my Aetna 3 month plan on October 27th and the papers were sent in for insurance approval March 3rd so just over 4 months (but I'm not approved yet). I spoke with the insurance company this morning and they are waiting for additional "clinical information" from my surgeon's office, whatever that means.
I was amazed at how fast those 4 months went by!
I was amazed at how fast those 4 months went by!
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