An alternative to a Lawyer...

I am a Patient Advocate specializing in Bariatric Appeals. I charge about 1/3 of what an attorney will charge to write an appeal, and I haven't lost an appeal yet. If anyone is interested in talking to me about my services, please email me. I am RNY post op 5/12/03, and I've lost 113 pounds. Fight the good fight! Roberta

I have emailed you and I am replying just in case it did not go through. I am very interested in what you can do for me. Please email me with any info you can share on how this works. See my profile. I have been denied. I was planning to get a lawyer but when I saw your post I decided to get more info from you first. Looking forward to hearing from you. Julia

Hi Roberta!!! I don't know if you could help me or not. I live in Florida and have United Healthcare through my employer. Our policy specifically states that it will not cover WLS of any kind for any reason. My employer is the one that manages the policies. Talking to my employer...they say that they cannot dictate what is covered. Talking to United....well, your employer is the one that bought the policy with the restrictions. Needless to say, appealing their decision has been pointless. I don't know if pressure from an outside source (like yourself) would make any difference. Anyway, thanks for your time.

Bobby, Sounds like you are in a tough spot. UHC is correct; your employer chooses the benefits as well as the exclusions. Most UHC administered claims are self insured through the employer. This means that the employer pays the dollar amount of each claim, and an administrative services fee to UHC for processing the claims. As you know, WLS is very expensive. Your employer chose the exclusion so they were not legally bound to pay for this surgery. There is no way to "put pressure" on your employer, but you can certainly attempt to persuade them to change their mind. I would appeal directly to your employer. Hopefully, you are a valued employee. I would let them know all your health issues, and that by having surgery and losing weight, these issues would resolve themselves. It's really a cost analysis of how much money they would save by actually paying for the surgery, rather than continuing to pay medical costs to treat your co-morbidities. You need to carefully consider the ramifications. They might not be aware of how much medical care you require, or would require in the future, unless you bring it to their attention. They may decide you are too great of a liability, and find a way to terminate your employment without it appearing as discrimination. You might decide to self pay, and go out of the country. It all depends on your financial situation, and if you want your future to be with your present employer. In these times, it is unlikely that you will be employed with your employer for the long haul, even if you are a valued employee. I know I've given you a lot to consider, and that it may be overwhelming. Fight the good fight! Roberta

Hi Roberta Ihave BC/BS New Mexico I have denied On appael & grievance the next is to appeal to the Insurnces review board, if you could please help me on what I need to put down on the part that says reason for review I would be great help to me. Colleen

Dear Roberta, I am a 31 year old who has battled obesity for 10 years. I have been denied by my insurance, due to an exclusion in my policy. I have two sisters who have been approved through another insurance company. one of them is my inentical twin. I feel desperate and depressed. My insurance is self funded through my husbands work. I have not attempted my first appeal. Can you help me?

I just received my first denial. I have PHCS-PPO which is underwritten by Trustmark. The Trustmark folks said I was denied because "exogenous obesity" is not covered in my policy. I immediately called to get a copy of my policy. Before I look at hiring a PA, how many appeals have you helped out on? I am currently trying to get a GR-DS procedure, not an RNY. Would this be any different. Thanks. Sincerely, Shelly H