Insurance Questions?

Does anyone know if their is a law stating how long an insurance company has to respond to a medical necessity claim. I have been waiting since mid January and still have not received a formal "yes" or "no". On several conversations with my local, they were telling me about a surgeon who is making a "deal" for 14K for bypass. I hope they are not expecting me to eventually change my surgeon and/or precedure? Do insurance companies have a right to tell you who to use and the procedure your having? If any of you know where I may find these answers, besides contacting an attorney and spending money, I greatly would appreciate it. I have my 2nd consult with my surgeon tomorrow and it kind of seems useless, but the girls in the office feel that with a tentative date and fee, the insurance company may respond quicker! Thanks Lisa

Hi Lisa, This is the most fustrating part the 3rd party in your medical care...the dreaded insurance company. I dont know of any law precluding a time limit on claims. However, I too am a patient of the Garber group. My surgeon is Holover, and I am scheduled for April 25th. Stefanie is the best when it comes to this, leave it in her capable hands and let her do her magic. I believe that your outcome, will be favorable. Would you please let me know from time to time how you are doing? All my best wishes for a speedy rely. Hugs Susan

Hi Susan - I know you didn't post about the Garber group- I just wanted to say hi - Im a postop patient of Garber & Holover.. Dr Holover is so great- he assisted Garber with my surgery, and I always tell him- he is my favorite doctor- and he blushes- LOL. Valentine's Day we had a patient support group, were you there? And before he left I gave Dr H, a small heart filled with chocolate..he blushed again..said it was the only one he got all day- LOL. All that aside- Dr H saw me in the hospital- he knows my history- as does Dr G - and he usually returns my calls. I love it because we have two specialists, not dependent on just one doctor- and they work so well together. We are very fortunate as patients go. Their skill and knowledge is what you pay for, and know you are in very good hands. About your hospital stay- the staff at Mercy is very good and efficient. Don't expect to sleep while you are in the hospital-they will have you up and walking around every 2 hours. And they also have a visiting nurse come to your house- 3 times: 2x before your drains are removed and 1x after. I don't know how long you are planning on remaining home from work- but 3 weeks is what I took- and I needed it. I would have taken more- I work in small office..so although you weren't posting about this- Just thought I'd give you the benefit of my experience. Also- what size clothes are you wearing? I had 3 tubs of clothes to give away and now have 1 very nice assortment of clothes- my favorites to be exact. They are 2 pairs of Avenue sz 26 denim pants in blue/ black and olive. The rest are all size 22/24, shirts, a skirts, I even have a suit - and a really pretty mauve top. Most of these clothes are in excellent condition- so let me know if you are interested. About me- I had surgery 8/15/05- I am -95lbs and doing well. Ive had no complications from this surgery- although I am anemic. My anemia was diagnosed years before and according to my last lab test- my numbers are all good. If you need any help- or want suggestions- or even if you want some Designer Whey protein (don't use what they give you in the doctors office- its yucky) I am giving away a full canister of Strawberry Designer Whey. I gave away one of Isopure. I just don't like them. You don't need to keep doing these shakes- but I am-as I workout a lot- and want the protein for my muscle recovery and to meet my daily requirements. Also- I grew up in Queens and I do miss it but love it on LI. I want to wish you a very joyful surgery and may God guide your surgical team and bring you through with a safe and positive recovery. Wishing you all the best - Donna 325/231/145

Hi Lisa- we've traded emails a few times..glad to see you are doing well. I think it may be because Dr Garber is out of network on most insurance companies - Dr Holover is not - and from what Im told- surgeons make more from ins companies when they are out of network. Also, I agree with the other lady- let Stephanie do her work. This staff knows the insurance companies inside & out- they've been doing it 10yrs. Also- Dr Garber has pull. When I was concerned about Aetna not approving last year- He told me- he would give a personal call to his contact there- and get one.It didn't come to that- but he is a recognizable name with insurance companies with this surgery. And to answer your question- the insurance companied do dictate policy regarding procedures- they can approve RNY and not lap or vice versa. Aetna was like that initialy- not approving lap surgery- until they discovered patients only were going for RNY and costing them a fortune in surgical fees - so they modified their plan. But also know this- that if they change or modify their plan- it shouldnt affect you NOW- it would affect you when your employer renews their contract- plus you've had your claim submitted months ago. Who knows- it could even be the insurance company messing up with the paperwork and coming in (its all done by US postal mail -not even a fax) thats taking so long. Keep the faith - You are in very good hands. Donna 325/231/145