Did you have to use an attorney to get your surgery approved??
Why would you need an attorney to write a letter? How is an attorney with no medical background going to prove medical necessity?
The first thing you need to do is contact your insurance company directly and ask them the basis of the medical necessity denial. Do you not meet their criteria? Then ask the surgeon's office to write an appeal letter proving the medical necessity. If you see a specialist for a comorbid condition a letter from them might also help. Do you not have all the records they request to review prior to approval? You may be able to obtain those.
The first step should be to identify what the lack of medical necessity is.
Hiring an attorney is an extra expense. I'm not sure if an attorney can force an insurance company to cover a surgery.
A medical policy is a contract. It states what is covered, what is excluded, any limitations and the criteria. If the criteria is not disclosed, even when asked, then is it not a breech of contract??? That is what a lawyer assists with. And, believe it or not, there are lawyers that deal directly with medical malpractice, contract litigations, etc. The attorney is not to prove a medical point, he/she is to prove a contractual obligation to cover a service. Based on over 8 calls to customer service in 1 month alone, "there is no criteria" other than the usual BMI guidelines ( >40, or >35 w/co morbidities). Sometimes just the thought of a lawyer getting involved is enough to have the insurance company take a closer look at its contract, review a individual's health history and the conversations between the patient and customer service. It is almost like a scare tactic. I am not afraid to fight for my medical rights.
Your human resources department should have a copy of your coverage policy. You should be able to read it. My employer actually has ours online. Are you being denied because the service is excluded from your plan? It sounds like you are being denied due to lack of documentation of a 3 year weight loss program. You need to contact them and ask what that consists of. Vitals taken at office visits documenting your weight? memberships to weight loss programs such as weigh****chers.
On one hand you say the criteria isn't disclosed and it's breach of contract, then on the other hand, you state "there is no criteria". I'm not which is the issue here.
I work in the medical field and while you can hire a lawyer it can be expensive and insurance companies have fields of lawyers at their disposal usually. it doesn't sound like you are being denied "medical rights" it sounds like your documentation doesn't meet their policy guidelines. Some major insurance companies even have their policy guidelines online to read.
They are not required to honor a contract if the documentation doesn't meet their policy criteria. These are two seperate issues and not a "medical right".
Request a copy of their coverage guidelines, and a detailed denial letter before you start the expense of a lawyer if you indeed want one. At least you could possibly get better information from the consult.
On one hand you say the criteria isn't disclosed and it's breach of contract, then on the other hand, you state "there is no criteria". I'm not which is the issue here.
I work in the medical field and while you can hire a lawyer it can be expensive and insurance companies have fields of lawyers at their disposal usually. it doesn't sound like you are being denied "medical rights" it sounds like your documentation doesn't meet their policy guidelines. Some major insurance companies even have their policy guidelines online to read.
They are not required to honor a contract if the documentation doesn't meet their policy criteria. These are two seperate issues and not a "medical right".
Request a copy of their coverage guidelines, and a detailed denial letter before you start the expense of a lawyer if you indeed want one. At least you could possibly get better information from the consult.
that is what your surgeons office is for - they have people that deal with insurance companies all day long - they know who to ask for and what to ask. You said your surgeons office told what you needed - 3 years -
Now 5 months later when the insurance company is telling you exactly what your surgeons office told you - you dont like the outcome - DID YOU THINK IT WAS GOING TO CHANGE = once they tell you the requirements and they told your surgeon, that is it.
I have Medicare and they were very vague over the phone on what I needed. I got all my information from my surgeons office. The only thing that I got from the insurance is that they dont preauthorize but as long as you meet the requirements you should be fine. Even with that - with no preauthorization, there was no guarantee. I have also heard of people getting preauthorization and then turned down - they told the person that preauthorization only means it probably will be paid but not quaranteed. - that is crazy - the people never should have told her that she was approved if she wasn't
Now 5 months later when the insurance company is telling you exactly what your surgeons office told you - you dont like the outcome - DID YOU THINK IT WAS GOING TO CHANGE = once they tell you the requirements and they told your surgeon, that is it.
I have Medicare and they were very vague over the phone on what I needed. I got all my information from my surgeons office. The only thing that I got from the insurance is that they dont preauthorize but as long as you meet the requirements you should be fine. Even with that - with no preauthorization, there was no guarantee. I have also heard of people getting preauthorization and then turned down - they told the person that preauthorization only means it probably will be paid but not quaranteed. - that is crazy - the people never should have told her that she was approved if she wasn't
The point I was trying to make is that this is MY policy...not my surgeons. The criteria should have been disclosed to ME every time I called and asked. Do you think we should rely on our doctor's offices to know what our policies cover? No. It is our responsibility to be our own health advocates. I worked for BCBS for many years. If we mis quoted a policy (like I have experienced) then we were reliable for covering the procedure. I specifically asked what the criteria is.If I hadn't, then I would see your point. I was just wanting to know what others had to go through when they were denied. Thank you for your response.
I guess you havent been on these boards for long and are new to the weight loss surgery world. It is totally different than anything else. Many policy's totally exclude it and others have specific things you have to do and other requirements come from the surgeon and some are from the state that add on requirements to your insurance requirements. I have medicare and there is no 6 month diet at all requirement but in some states there is - Medicare is a federal medical insurance policy and should be the same for everyone with the same policy.
Due to these inconsistancies, it is known and the surgeons know it, they have there own billing departments.They are the ones that answer all medical insurance questions, they are the ones that submit your claim, they are the ones that write a letter of medical necessity for you other than your PCP - they do a ton of stuff for you. That is what they are there for and if they tell you a surgery wont be covered or you have something that is required to be done preop - you need to listen to them - they know what they are talking about - that is what they are paid to do, 40 plus hours per day just get weight loss surgeries paid for - they fight for us in all ways.
So, I am not trying to be mean for you - I am just trying to get you to understand how this community works and how the insurance world works for us. Unfortunately, the people that answer the phones dont have all the answers - they try but they just cant. Trust your surgeons office, they usually do have the answers
I understand what you are saying the insurance should but they dont
Due to these inconsistancies, it is known and the surgeons know it, they have there own billing departments.They are the ones that answer all medical insurance questions, they are the ones that submit your claim, they are the ones that write a letter of medical necessity for you other than your PCP - they do a ton of stuff for you. That is what they are there for and if they tell you a surgery wont be covered or you have something that is required to be done preop - you need to listen to them - they know what they are talking about - that is what they are paid to do, 40 plus hours per day just get weight loss surgeries paid for - they fight for us in all ways.
So, I am not trying to be mean for you - I am just trying to get you to understand how this community works and how the insurance world works for us. Unfortunately, the people that answer the phones dont have all the answers - they try but they just cant. Trust your surgeons office, they usually do have the answers
I understand what you are saying the insurance should but they dont
I had to
-prove I was over 40 BMI (35 with Diabetes or other health issues)
-show a 2 year weight history
-show I was on a supervised diet for at least 6 months over the past 3 years
-do the various tests
What a surgeon friend told me is that insurance companies want to make it hard for a couple of reasons:
- want the patient to use surgery as a last resort and not use it without trying non-medical solutions first
-want to assure you are committed to the surgery
-hope you will switch insurance companies in the 6 month period when you start the process so they are not responsible
-prove I was over 40 BMI (35 with Diabetes or other health issues)
-show a 2 year weight history
-show I was on a supervised diet for at least 6 months over the past 3 years
-do the various tests
What a surgeon friend told me is that insurance companies want to make it hard for a couple of reasons:
- want the patient to use surgery as a last resort and not use it without trying non-medical solutions first
-want to assure you are committed to the surgery
-hope you will switch insurance companies in the 6 month period when you start the process so they are not responsible
I have heard that as well. The insurance I have will always deny then you have to appeal.They are counting on the fact that most individuals will give up...or like you said, switch insurance providers. Thanks for your input. I was just trying to see what others have been through to get approved after a denial...not lectures. So again...thanks.
I am sorry if you take these posts as lectures - I am just trying to help you with all my experience
- I had my surgery in 2008, started going to surgeons for the first time back in 2000 but my insurance didn't pay for it back the, I found out Medicare started paying for it in2006, so I started persuing it again and went to 7 different surgeons over the 2 years to finally find the one that Iliked and felt was qualified to do my very complicated RNY. A few said they wouldnt do it
since it was too complicatted but there were 3 or 4 that were very happy to dn it. I then narrowed it down to 2. One of them had a terrible insurance department and wouldnt do the legwork necessary to get it approved, that is what they are there for, so I went looking further and that is how I found my current one. They are great and do everything for you and got everything paid for except my yearlyou deductlble.
so, please dont take anything I am saying as a lecture - I am just trying to help you out and give you some guidedance from my years of experience. If you dont want any of my help going forward, I wont answer any of your posts anymore but I do go out of my way to help post ops with there questions of lab work, supplements questions, thyroid questions, diet questions, infomation about vitamin deficiencies and anything else that I am able to answer.
- I had my surgery in 2008, started going to surgeons for the first time back in 2000 but my insurance didn't pay for it back the, I found out Medicare started paying for it in2006, so I started persuing it again and went to 7 different surgeons over the 2 years to finally find the one that Iliked and felt was qualified to do my very complicated RNY. A few said they wouldnt do it
since it was too complicatted but there were 3 or 4 that were very happy to dn it. I then narrowed it down to 2. One of them had a terrible insurance department and wouldnt do the legwork necessary to get it approved, that is what they are there for, so I went looking further and that is how I found my current one. They are great and do everything for you and got everything paid for except my yearlyou deductlble.
so, please dont take anything I am saying as a lecture - I am just trying to help you out and give you some guidedance from my years of experience. If you dont want any of my help going forward, I wont answer any of your posts anymore but I do go out of my way to help post ops with there questions of lab work, supplements questions, thyroid questions, diet questions, infomation about vitamin deficiencies and anything else that I am able to answer.
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