Need some direction Re: denial

Marcel, PCP- Primary Care Physician(DR) just got done having a 30 minute conversation with Blue Cross. The referral NEVER went to them it was denied at the office. This is a good thing as the psych eval and initial request never made it to BC. As far as they are concerned that other stuff never happened. They suggested I change PCP BUT it won't take effect unti MAY 1. that gives me time to interview potential rs.

That is the most ridiculous psych eval justification fr not having WLS I've ever heard, that is the exact grounds for having the surgery.  If you could diet successfully , you wouldn't need the stinkin surgery.  What an idiot. Good call calling Ins and finding out it was never sent to them.  I with the opther guys, find out who your surgeon recommends and then who you Insurance covers and when you get a hit from both ends, go for it.  Don't let it get you down, let it make you more determined.  Folks with Cigna insurance get turned down usually at least once as part of the processs to get approved.  What a game these companies play.  Then the psych eval,...anothr scam much of the time. Hang on.  Alot of us had to endure it too and we made it through.  You will too if you just stay with it.

Here's my take on this, and I was denied a couple of times because they wanted to do things a bit differently for me. First of all - everyone is saying to get a PCP that supports the surgery.  What you need to do is find out the exact reasons you were denied.  If you were denied straight up because your PCP is against the surgery, then yes, a new PCP is in order. However, if your PCP is open minded about the surgery, and you were denied for other reasons, such as a heart problem, or something along those lines where they say the medical risk is too great, then find out if there's something you can do about it from that angle.  I had to lose a bit of weight before they'd do it.   If it's the insurance company that's denying you, then you can appeal it.  There are (I'm sure, I haven't looked myself) advocates and attorneys that will help with that.  If it's the insurance company, get your PCP to refer you to someone else for a second opinoin you can submit to your insurance company.   Finally, talk to people who are in your medical group who have had the surgery.  FInd out thier story and if they had difficulty.  It could be just that your medical group is whiny about it, and you just have to appeal and fight for it. It took over two years before I finally got my first surgery leading to my gastric bypass.  I understand your pain.  I agree with these guys, you need to have a PCP that's open minded about the surgery.  But the best advice I can give:   Before you go off and get pissed that the PCP is denying you, find out the reasons.  If it's just that he is against the surgery in general, then it's time for a new doctor.  But if he's denying you because there's a medical condition, find out about that and see if there's anything you can do to correct it. Good luck!

Dave, it been an ongoing battle with the PCP to even get the refferal for the psych eval. Hes not a fan and has never had a patient go through WLS. He tried to tell me I would lose 3-5 Lbs a month WITH WLS. Since I have been averaging 4LBS a month it was not neccessary. that conversation was 2 weeks ago.  I thought I could hlp his see the light about WLS but it seems to be a lost cause.  I did find out I was NOT denied by the insurance CO but some administrative review panel at the medical group, who I am sure backs up whatever the Doc wants.

 

thanx again for your input guys

Hello, I agree with the other suggestions re. finding a shrink that actually supports WLS - just make sure that person isn't affiliated with your surgeon's practice. Be careful about sending in too many denials, that could really hurt you. You might consider contacting Walter and Kelley Lindstrom of the Obesity Law and Advocacy Center ... (www.obesitylaw.com). After 3 and a-half years of fighting with the insurance company's BS, they stepped in and got an approval within 4 months. The cost was $850 but well worth it, surgery was mid-Feb. and now doing great.