Insurance Approval Dillema for PS - Help Please!

OH Men who have been through Plastic Surgery (and dealt with insurance), A little background...last year about this time I had a plastic surgery consult for a TT.  At that time, I was almost certain coverage though Cigna PPO would be denied.  As expected, some 6 weeks later I received that denial with Cigna stating that it would not cover plastic surgery that was considered cosmetic. Fast forward to the beginning of last month, October 2007.  After a bike ride I discovered two small water blisters on my lower right abdomen where I've got loose skin as a result of my weight loss.  One of them broke and I ended up with an infection that got out of control rather quickly.  Ended up I had MRSA (drug resistant staph) which I've dealt with an entire month.  My PCP and the specialists at the Wound Care Center are all in agreement that my only option to address this issue is removal of the excess skin.  Today I met with the Plastic Surgeon and he concurred saying this time around the procedure being requested is still a tummy tuck, but is re-constructive and a medical necessity - not cosmetic as it was last year.  He says though that insurance is still likely to drag its feet on approval even when it's deemed medical necessity. Here's the issue...the Plastic Surgeons office says it will take 4-6 weeks for approval.  I'm very concerned with this timeline as my insurance through my employer changes on 1/1/08 and I will no longer have Cigna and will be moving to United Health Care.  Waiting for Cigna's approval puts me dangerously close to the end of the year and the Plastic Surgeon said he was not optimistic about approval by years end.  If approval is not received, I then go for approval with UHC my new carrier - all is not lost.  Or is it???   It's highly likely that UHC will deny the claim immediately stating the issue is a pre-existing condition and will not pay. Does anyone know if there is a way that I can possibly expedite the approval process?  This issue is not going to go away without the surgery.  I had absolutely no control of when I experienced the wound and subsequent staph infection - but because of the long approval process at Cigna, I may not be covered at all as a result. Any advice would be greatly appreciated! Cards Fan Springfield, MO

HI - I can't tell by what you wrote if you work for a decent sized company or not but if you do, the pre-existing clause may not apply as you move to the new plan on January 1.  Some large employers exclude that clause if you are moving from one plan to another (as opposed to being uninsured to newly insured).  I'd say to check with your benefits person on this. JP

Hey CF,

I've worked in Health Care for 20 years, and the best chance you have is to get on the phone yourself and talk to the insurance company and talk to them.   You are your best advocate.   You can get your own medical records, and talk to the claims department.   I recently had some medical claims that were denied, and I went all the way to the Medical Director of the Insurance company to get them approved.  

Remember. to the insurance company, you are just a number - a piece of paper.  And a denial means that they make more money.  It's a very sad statement, but unfortunately it's a true one.

Gather copies of your medical records from your PCP and get on the phone with your claims department and let them know you have MRSA, and that your health is at risk, and the surgery is necessary.   If you don't get results from the "clerk" that answers the phone, demand that you talk to a supervisor, and DO NOT take NO for an answer.  MRSA is nothing to fool around with.   Keep going up the chain until you get results.  Be polite and professional, but be ASSERTIVE!!!!!!   ADVOCATE for yourself!!!!!!!!!!   THE SQUEAKY WHEEL GETS THE GREASE!!!!!!!!!!!!!!!!!!   IT'S TIME TO SQUEAK!!!!!!!!!!!  By the way - I'm a social worker..... I know how to squeak......  

Good luck bud....   

Chuck

Hey cards...2 things..... 1) I use to do HR type stuff at my old job...pre-existing condition clauses are usually written out of a contract in big empolyeers, because they don't want to have an empolyee revolt.   So basically there should be no exclusions based on pre-existing conditions, but you can check with your HR department (if you have one) to confirm.   Do it now, and save yourself the stress. 2)  In NY (and maybe MO) if you can show that you have had continious coverage for the term of the new insurance companies exclusion, they have to waive the exclusion for pre existing conditions.  For instance, if you wanted WLS, and had COBRA benefits from your old job, and got a new job, and waited for your new jobs insurance to start because it had better coverage then your COBRA benefits, as long as you showed that your coverage didn't lapse in the last 12 consecutive months, they would not be able to exclude you from having WLS based on the pre existing obesity issue. 3) boy i had 3 things to say....lol...i agree...be the sqeaky wheel...just because it normally takes 6 weeks for approval doesn't mean it has to take 6 weeks.  You can push your doctor's office staff to push for approval...you can call the insurance company daily (yes you can do that and they ahve to take your call), and you can "force" them to move a bit faster.   While many people on this fourm waited weeks for insurance approval from their insurance company.....i got mine in 2 business days because my doctors office is extremely efficent. 4) Ok for me only having 2 things to say.....lol...if you do have an HR department..call them monday and find out if there are any written exclusions against Plastic or reconstructive surgery in the new policy from UHC.  Companies are increasingly excluding things such as WLS and PS and PS loopholes to save money on policies...while we are in general paying more for policies....we are recieving less and less every year. IT SUCKS...but it's the truth.  I say to call and find out because this will help you determine how fast you need to move on these issues.  I hope this helps Scott PS If your sugeons office is willing to work with you, many will pencil you in with a tentative date, so that you have a date reserved, and will hold it up to the week before surgery......pending insurance approval.

….Only to add but “Good Luck!” Lots of good info from the guys here. I would also add, do it all- “In Writing.” Toss a few bucks at the post-office and have certified mail “Over-Nighted.”  Fax when ever you can. Call to inquire if they received your fax. They are notorious for “forgetting” or “missing” calls. I shopped around awhile on my PS, But got my approvals within 2 weeks. Approval(s) Got two different procedures approved with two different Surgeons. Then I was free to choose what seemed best for me. The MRSA and the “continuous coverage” are both on your side. Has your PCP written a letter of med necessity as well? Get them to.  And a dermatologist, MRSA Specialist, etc… Who ever in the Doc Community thinks your Abdomiplasty is a good idea, Get ‘em to sign a statement to that fact. I had 4 different docs’ letters in hand when I began. Helps a lot.  Or so it seemed. Keep us updated! Best Wishes- Dx