4 appeals later insurance approved removal of band but I had to self pay

Hello,

I'm was a lapband reciepent for 8 years until Dec 2016 went I started having pain under my left breast, where the band sits. After consulting with my surgeon who sent me to get an Upper GI it was determined the band needed to come out. I have struggled all my life with weight so no way was I getting this removed and not getting the sleeve. Long story short my insurance comapny basically said nothing was wrong with me and that they would not approve the removal or revision. My doctor did a peer to peer went through my history.. still no. At this point, I'm still in pain only on liquids and my doctor didnt want to remove the fluid from my band because he was concerned that it would slip and make things even worse for me. I then did a member appeal with evidence that there were issues with the band, still a "NO". Now my health was at risk and I couldnt wait any longer to get the band out of me, so as I continued to fight the insurance company I scheduled to have my band removed and then revised to the sleeve. Basically, I had to pay out of pocket or the hospital wounldn't even schedule my surgery. Had my surgery on Feb 13th and my surgeon said the band was in bad shape and that scar tissue from the band had attached itself to my liver. All this and I still continued to fight with my insurance company. I did another appeal after my surgery and this time I was able to be a part of the review. i sent them pictures of the slipped band and liver and also my surgeons dictation that he did during surgery. FINALLY!! The insurane company said that they would now cover the removal of the band.

Here's my delimma, how do I get my money back from the hospital? Since I was a self pay they did not generate any claims to submit to my insurance company but now my insurance company is looking for those claims to pay? I've called hospital billing and its scary whent the patient knows more than the people who are supposed to have the knowledge of how billing works. I paid a lot of money to have all this done and I'm ok for paying for the revision but I should have money returned to me for the removal of the band since it was covered.

Has anyone had anything similiar to them happen when their insurance wouldn't approve you however you went ahead with the surgery and then after months of fighting them they finally approved you?

Thanks!!!

First you work with the hospital to have the insurance claims generated and submitted to insurance.

When those claims are generated and have been paid, you write a letter to the hospital requesting the money be refunded to you.

It will take time, so be sure to have everything documented in writing.

In the insurance world there is a thing called "timely filing". Which means the hospital and or the doctors only have so long to bill the insurance company for a service in order to get paid for it. Some insurance company's give up to 6 months, but most only give 60-30 days. As long as the hospital has the approval from the insurance company have them bill the insurance company ASAP before time runs out.

Now that being said they (the hospital/doctors) may be trying to run out the clock on you. Believe it or not cash pay people sometimes pay more then what an insurance contracted rates are.

Good luck

SJ

File a request for member reimburstment.