Getting very down about the runaround /delays from Aetna
I've posted many times along my journey. I was scheduled for a lap RNY on 7/27, but it was cancelled due to incomplete paperwork. My surgeon rescheduled for 8/11, as since Aetna was only missing one thing, she felt it was plenty of time to get it to them.
I called Aetna today and they say they STILL don't have the what they need: proof that a DOCTOR supervised my diet, not just a nutritionist. The fact that I saw a physician 4 times in 3 months is in the paperwork. I'm not sure WHAT Aetna is NOT seeing. The precert person at Aetna says "Oh well, we don't have what we need, you better not count on having that surgery as soon as August 11!" when I said "What part of 4 doctor's visits are you not seeing here?
My surgeon's office says that this is typical Aetna 'stall tactics' -- that they will keep saying they need more things to avoid paying the claim.
I was able to get the PERSONAL fax number of the nurse handling the case, whose assistant has been giving me the runaround. My hospital faxed the papers TODAY, to her DESK (before I was being told 'well we don't get the faxes directly, we get them 2 days later' so I got a nice unsuspecting customer service rep to give me her direct line). I call her assistant, tell her it's coming and that I'll be calling back. WHen I call back , all of a sudden they are having COMPUTER PROBLEMS and she can't see anything. I said "I thought you were her assistant? It's being faxed to her desk!" She gave me a line of nonsense and said she'd call back later today. (She didn't)
I just feel like no one is taking accountability and that my insurance is in NO hurry to approve anything because $30000 is a lot of money! I am getting more and more down and wondering if I'm going to ever get to surgery.
Another issue for me is that we have a $3000 family maximum payment per year for Aetna, and we are already up to $2200. I would only have to contribute $800 to the surgery. If they deny me and I have to go through appeals and it goes past the first of the year, I'll be paying $3000. That is a huge difference for me and my family.
ANy words of experience/encouragement are appreciated--and needed!
a few pounds below goal right now!
Now my Managed Care Group has been the biggest ASSes during this process. I call my insurance PacifiCAre and get a different answer and then I place a formal complaint about this particular lady that works in that managed care department. Guess what, they over turned the denial to allow me to go outside of my Managed Care Group within 24 hours and that certain someone made the statement "I don't know who you know or how you did it but the original denial was overturned. We don't usually overturn them on our end and you usually have to appeal thru the insurance company directly." Well it wasn't for her to know...when I called her I already knew it was approved I just wanted to see if she would look at it or not.
So all in all try to stay positive and remember you are your own advocate. You already made one milestone continue to do so!
Sample Letter of Medical Necessity
(date)
(Insurance Company Name and Address)
RE: (Patient Name) Date of Birth:
To Whom it May Concern:
has been a patient of mine for years. Patient is tall and weighs lbs. with a BMI of . Patient has been excessively overweight for some time now and will benefit from Bariatric Surgery.
In addition to morbid obesity, the patient is suffering from the following comorbid conditions: (e.g. Exertional dyspnea, urinary incontinence, sleep apnea, hypertension, diabetes, degenerative joint disease, osteoarthritis, hypercholesterolemia, hyperlipidemia, shortness of breath, etc.)
Patient has tried many methods of weight loss including diet pills for length of time with pounds lost and pounds [regained or not regained]. Physician administered diets for length of time with pounds lost and [regained or not regained], Weigh****chers, etc. The patient is limited due to her comorbidities in her ability to exercise but has tried [list all attempts and any successes or regaining of weight].
Family medical history is positive for [e.g. obesity, hypertension, diabetes, hypercholesterolemia, etc.]
I am respectfully requesting pre-authorization for bariatric surgery to be included in patient’s benefits and coverage. Thank you for your kind consideration in this matter.
Sincerely,
****Have your pcp re enter this information and have him be specific on all the details and list your four visits on forms like this. My surgeon's office uses these to give to the Pcp's hopes this helps. If you are able go in to see your pcp and talk with him/her even if you have to make appt and pay copay. this is your life.
Physician:
Address:
Phone: Fax:
Brief Office Visit
Patient Name: Date: Wt: DOB:
Reason for Visit: Morbid Obesity
Encounter Data:
(Please check all that apply)
o Diet discussed o Exercise discussed
o Behavioral Changes o Nutrition discussed
o Handouts given o Recheck in one month
Physician Signature: Date:
---------------------------------------------------------------------------------------------------------------------
Physician:
Address:
Phone: Fax:
Brief Office Visit
Patient Name: Date: Wt: DOB:
Reason for Visit: Morbid Obesity
Encounter Data:
(Please check all that apply)
o Diet discussed o Exercise discussed
o Behavioral changes o Nutrition discussed
o Handouts given o Recheck in one month
Physician Signature: Date:
Hockeymom87 · 0 replies · 604 views
