Insurance Denied Me!!! Please help with any suggestions!!!

Hello,

I have HAP insurance through my husband’s job and I have been trying to get approved for surgery for at least 6 months.  In that time I have gotten three different denial letters for this procedure.  First time it was because I didn’t have enough information for them to review, so I sent them the information they were asking for!  The second time is because they wanted my records from a doctor that I had been seeing in this weight loss program for over a year, I sent them that information!  Now, this third time was because the doctor that I saw for over a year, they said that he “was not a hospital affiliated doctor."  I have appealed three times and I don’t know what else to do or where to turn too!!!  Is there anyone out there that can give any advice on what steps to take to get this approved!!  I am in tears writing this letter and need help desperately!!! I will try anything!!!

Thanks,

Carol

Call your insurance company daily, ask what else is needed, keep on your surgeon office to appeal and resubmit.  PERSISTANCE gets the job done and alot of it comes from the patient.  I kept getting the same runaround and called and would get 2-3 different answers in the same day.  I think they finally knew I was serious and was not giving up and finally approved me and now I am 5 weeks out and it was worth every phone call.  Good luck.

First, understand that this is a business decision for your insurance company.  They are using their contracts to determine whether to pay for the coverage, and they seem to have found another way to deny based on how your situation lines up with your contract.

Your job is to:

(1) Get all objections from them in writing so you can address them all at once.  Reply to the most recent letter in writing asking for all of the reasons why the surgery is being denied and what would need to be done to satisfy those requirements

(2) Thoroughly respond in writing to every issue that they provide.

(3) Include the financial benefit TO THEM for approving your surgery in your response.  While this isn't absolutely necessary to obtain approval, they will be much more likely to approve a "borderline" patient (from a contractual standpoint) if they think it will be more profitable over the long-term.  Fortunately, weight loss surgery is an extremely profitable investment for the insurance company over the long-term.

This page walks through the instructions and has a sample health insurance appeal letter.

You should also seek the assistance of the HR department from your husband's company.  They (along with their employee benefits broker or consultant) can work with the insurance company on your behalf to speed up the process.

Good luck!

Jeff