Why are they denying you?  What is their written reason?

Thank you. I am going to follow that... If they refuse me, then oi!

This is a very unfortunate situation, however, I would like to make a little clarification on behalf of the office.  My surgery was 6 years ago and insurance was much easier to get approvals for those of us that were overweight and had medical issues.  As time has gone on you'd think the process would become easier... but on the contrary.... Insurance doesn't seem to care what is GOOD for the patient... it's all based on trying to put up hoops and make the patients go away from the surgery so Insurance doesn't have to pay. 

I am sorry you had this experience, but in defense of the office, UHC and Oxford for over a year have been aware that the docs were not going to remain in Network if the Insurance did not agree to pay then on a better scale.  Doctor's are required to notify the Insurance 60 days before end of contract if they are not going to continue.  These docs were told last year that Oxford would begin paying on a scale equal to other Insurance companies, but never came through with a contract to do so. 

the Office went back to UHC/Oxford FOUR MONTHS in advance of their contract renewal to advise if they did not come to a new agreement they would not stay In Network.  The Insurance company by law must notify patients in writing 30 days prior to a doctor going out of network.  The Insurance Company FAILED TO DO THIS.  IN ADDITION, when Doctor's office spoke to Insurance Rep. about this UHC told the Office they WERE NOT to notify the Patients, as that is the requirement of the INSURANCE COMPANY. 

So as much as I do feel for the patients, I see the frustration on BOTH SIDES.  UHC/Oxford has ADMITTED that they have made the ERROR by Failing to Notify their patients.  Their SUGGESTION TO RECTIFY this situation was ... to make things RIGHT... The DOCTORS go ahead and see all their patients for next 60 Days while UHC/Oxford can get their paperwork together and notify patients as law requires.  HOWEVER, this SUGGESTION Did NOT Pay the doctors ANYMORE for their procedures.  So The Insurance just Expect the DOCTOR to Continue to take the bullets for the Insurance Companies error. 

Had the Insurance Company said to the Doctors.... We made the mistake but would like you to continue to see our patients until we can NOTIFY THEM... and We Will PAY you at our OUT OF NETWORK RATE DURING THAT TIME... I'm sure the doctors would have agreed to do so as this would have given a compromise to all parties involved. 

BUT FOR THE INSURANCE TO ADMIT TO THE WRONG DOING WHICH PUT THE CARE OF MANY PATIENTS IN FLUX AND TAKE NO FINACIAL RESPONSIBILITY.... ACTUALLY ASK THE DOCTORS TO SHOULDER THAT BURDEN IS REDICULOUS! 

The Insurance FOR the PAST YEAR Has Strung the Doctor's along thinking they would come back with a Contract for Nov 2010 that would be more competitive rates.  In Good Faith doctors stayed IN Network for an additional year.  UHC/Oxford was well aware that they would be expecting an increase and when they did not offer a competitive contract the doctors were forced to Leave the Network. 

So... in the end I do feel bad for patients that were affected by UHC/Oxfords mistakes.  And If they were MY INSURANCE PROVIDER I would be putting in a complaint with the Division of Banking and Insurance with the STATE.  I am sorry that patients were inconvienced by all this.  The doctor's have not and will not turn away patients, but the office is out of network and patients charges will be processed to their  OUT OF NETWORK Benefits.  So Patients will still be seen, but if you are covered by UHC or Oxford call your member benefits to check what your Out OF Network Benefits are. 

Sometimes we forget as patients that it is our responsability NOT the Doctor's Office to know what are benefits are.  Member Services on the back of your card is where you call to find out.

Dr. Bertha's group has Insurance People who do verify benefits prior to procedures, this they do as a courtesy but ultimately it is the patients responsibility to understand their Insurance benefits.  No One should go to the Hosp. for a procedure without having confirmed with member benefits if it is covered. 

There must be more to the story ...UHC has been known to drag their feet on approvals... I can only imagine how slow they are with contract negotiations for their providers.  I would bet that this situation resulted from red tape created by UHC.

IF UHC approved the procedure and now your surgeon is out of network, I would think UHC IS OBLIGATED to help you find another provider that is in network given the fact that they approved the surgery.

Good luck as  you continue your journey.

 

I'm amid the appeal process for a revision (specificall Band Over ByPass).......can anyone recommend an attorney who can help with this sort appeal?  We're in the Pocono's of PA... surgeon in NJ.