You CAN request in network authorization with Aetna

Greetings all.......and let me just thank all of you for the wealth of knowledge and shared experiences on this forum.  I have been on a rollercoaster ride this past week regarding if I will be approved or not. I have Aetna HMO and have been told they do not pay out of network.....that I would have to switch to PPO coverage during open season ....putting my new life on hold for 6 more months. Well.....I do not accept that. I finally talked to the RIGHT person at Aetna who told me to have my surgeon request authorization for in-network coverage, due to the fact that my surgery is medically necessary....and there are NO in-network surgeons in my area. She said they have to call provider services and request the authorization form. For more information regarding Aetna and their take on bariatric surgery.......check out their Clinical Policy Bulletin for Obesity surgery and it lists all their requirements. I will NOT give up..........I want to be on the Losers bench so bad. I am 5"6', 260 lbs and my goal is 165 lbs for this time next year....so I am hoping for the LapBand to help me achieve that. I hope this helps some of you as I have been helped here. Have a great weekend all.......Eileen.

HI I ALSO HAD AETNA HMO IT WAS A FIGHT BUT THEY FINALLY APPROVED ME. I WAS GOING TO A DOCTOR OUT OF NETWORK BUT I SWITCHED TO DR. BILOFF IN WEST ORANGE SATISFIED THERE REQUIRMENTS AND I WAS APPROVED. ALSO ANOTHER GOOD DOCTOR IS DR. JEAN-BAPTISTE OUT OF MUHLENBERG HOSPITOL IN PLAINFIELD I THINK HE TAKES AETNA.ANY QUESTIONS I CAN HELP YOU PLEASE FEEL FREE TO EMAIL ME [email protected]. HARRIS

Hi Harris.....thx so  much for responding. I did a Doc-Find on Aetnas website for bariatric surgeons in NJ and it came up zero. so basically, ALL bariatrics in NJ are out of network.....according to Aetna. So......are you telling me that Dr Biloff was IN-network? This is so confusing. Do you mind telling me what you paid for the surgery? I really would prefer to stick with Dr Mehta......his office is 5 minutes from my job and just 15 minutes from home. But....if we are talking thousands of dollars........then I would have to consider switching surgeons.  Thanks for any help you can give me.....and best of luck to you as well; Eileen

Eileen,  I had the same problem when I did an in-network search on Aetna Navigator, but when my PCP contacted Aetna directly, they told me that Dr. Louis Fares in Trenton was Aetna-approved for Bariatric surgery.  (He is listed under general surgery, though, which is why he didn't show up in my search.)  I'm not scheduled until July 19 for surgery, but I can tell you that I LOVE Dr. Fares and his team of specialists.  There may be someone closer to New Brunswick who is also Aetna-approved, so be sure to contact Aetna directly to ask! Another thing to remember is that I read recently that if the hospital you choose is approved, you have the right in NJ to have a doctor who does not accept Aetna perform the surgery if you are willing to pay the surgeon's fees.  So, if you wanted to go out of network, so long as you had the approval for the surgery and for the hospital where it would be performed, you wouldn't have to pay for the whole thing out of pocket.  Definitely check with Aetna though about specialists that may not come up in the provider list! Jacqi

It is my understanding it is the doctor himself that does not take the in-network coverage with Aetna.  My surgeon does not take Aetna HMO but will take the PPO.  Good luck. 

I see your surgery date is approaching....best of luck to you!!! I thought about Dr Bertha.....are you having the surgery in New Brunswick? If you are.......where will the follow ups be? I live in New Brunswick so Dr Mehta would be ideal for me. Aetna told me that ALL the bariatrics in NJ are out of network.......when I did the doc find on their website it came up with zero for all of Jersey. Aetna said I would have to wait for open season for PPO....but then said I should have Dr Mehta request authorization. It seems like a contradiction to me. It all depends on who you speak to. The girl in Mehtas office said straight away aetna hmo wont pay.....she never even suggested I have the doctor request authorization. But when I called again....after I talked to aetna......a different girl in the office said yes that is the way to go. This is very frustrating. Is that what you did....ask aetna to authorize out of network? I appreciate any advice you have........and I will be thinking of you in the coming weeks. Best of luck before, during and after your surgery. Eileen

Thank you for the well wishes. I am still waiting for insurance approval.  I am having surgery at Morristown Memorial Hospital.  I was fortunate in that when I found out that the surgeon did not take Aetna HMO it was close to the renewal time for my insurance.  My understanding was that it was the surgeon's decision and not Aetna's.  Since the insurance is through my husband's business I was able to tailor order my insurance so it covered WLS and would be accepted by the surgeon.  So I changed it to the Aetna PPO plan with out of network benefits.  Dr. Bertha came so highly recommended by my PCP (he thinks so highly of him he did not even want to recommend anyone else) that I wanted to do what was necessary to have him do my surgery.  Keep us posted. I will be interested to see if the doctor will do the surgery with your current insurance.  I know you do not want to wait longer but if it ends up that you have to wait for open enrollment then look at it as an opportunity to learn more about the surgery and what to expect post op.  I know I am glad I did not have the surgery when I first decided I wanted it because I have learned so much more and feel I will be more successful.  Good luck and let us know what happens.

Hello Eileen,

I was just banded June 6, 2007 by Dr. Jean Baptiste.  He is part of the Solaris Group that owns Muhlenberg Hospital.  I had done a great deal of research on good doctors and Dr. Jean-Baptiste's name came up frequently with rave reviews.

I can tell you first hand that he is an expert and his staff is impeccable.

I would call the office and ask directly if they accept your insurance.  If by chance they do, it would be a total win win situation for you because you would be in the best of care.

 Feel free to e mail me directly with any questions.

[email protected]

 

I HAD THE SAME PROBLEM YOU, DID THE SEARCH NO BARIATRIC SURGEONS . BARIATRIC SURGEONS USALLY ARE UNDER SURGEONS AETNA WAS THE ONE *****COMENDED MY DOC. HARRIS

Really.....they suggested him? That's cool. Let me see what happens with Dr Mehta. What ype of surgery are you having, and did you get a date yet?