CAN ANYONE PLEASE HELP ME???

Hello, please forgive this long post but I need some advice from anyone who may have the information or know-how about this insurance issue.. This is my story.. Since 1997 we have not had any insurance so I went to a clinic for low income people since like 2001 or 2002 for anything that came up, like my hypertension female stuff etc.. (In Dec 2003 my husband finally got some insurance through his new job.) When I began this journey into WLS (Dec 2003) I went to them asking for a referral and because all of my appts to that time had been based on our income, they said no they could not write any referral for me..they were not on my insurance list so I got my records from them and went to an old gyn I had seen a few times, and she was the one who gave my referral to my surgeon. Thing is I only saw her a few times over the last few years. Today the insurance lady at my surgeon's office called me to tell me the insurance wants to prove pre-existing something or other, so I called to speak to the insurance company to see what they wanted exactly..her answer to me was that they want any records from Sept.1,2003 to Dec 1,2003. They will not cover anything that was treated in those dates. But I can wait until December 1 this year to get that waived and then proceed to try and prove medical necc for this surgery. This however has me very worried, I was not seen for anything by the Gyn during those dates, I may have been seen thru the low income clinic maybe but nothing about weightloss. However, I am trying to use my GYN as my PCP and she wrote me a letter saying the diets didn't work for me and listed them for me and said she had been my caregiver during those attempts and they didnt work for me..(however we have no medical records documenting anything, if they ask for that proof) IF I send records to them from the low income clinic they will wonder why not the GYN clinic if she was my PCP .. I dont know .. I guess I just do not know what to do next.. I do have records from the low income clinic however I am afraid to send any of them due to the fact I want the GYN to be in thier records for my insurance company as my PCP , otherwise my WLS referral won't be worth anything and I will have just wasted all of my time and energy these last mths going through all of this! Do I call the GYN and ask for a letter saying I was not treated during those dates?? OR not send anything and wait until Dec 2004 to send off for approval for the WLS?? That would be the one year date of being on this new insurance. How should I handle this? I am afraid somehow of screwing myself over on this one somehow and then when Dec gets here I will be denied for some reason.. PLEASE if anyone knows how to handle this, please please email me.. I am desperate.. I want to take care of this ASAP so when Dec gets here I can get this approval process done with and get my surgery already.. I sure would appreciate any and all advise on this matter.. THANK YOU! Dawn

Dawn, I'm not sure what insurance you have but mine did not require anything but weight and blood pressure taken during the time frame that they require. My doctor (who happened to be a resident at the time) wrote a letter to my insurance company that was detailed in my attempts at losing weight and he included all of those weights and blood pressures. Maybe if you explain the situation to your GYN and provide her with a list of weights and blood pressures during that time frame she may write a letter including them in it to help speed up the process. Just a thought. Hope it all works out for you. Anne

Dawn, Another option, write a letter yourself for the Doctor to sign. If you have been seen at the clinic, and they are at least familiar with you and your health history, write the letter, schedule an appointment at the clinic of which you have been attending, and ask the Doctor to read and sign it right then and there. It can go something like To whom it may concern: Dawn Boltin has been a patient in my clinic for the past xoxoxo months (or years as the case may be) during which time I have treated her for xoxoxoxo (again whatever the case may be). and so on and so forth. You can get ALOT of great ideas from here by reading various bios.. I hope this helps hon, this is what I did, and it worked for me!!! By the way, BCBS wanted a 6 month diet history, and I didn't have one, I just submitted what I had, and they approved me! Lots of times they just want to delay the ineviatible, I heard this before my approval and thought, yea right, but I found it in my case to be very true. Best of luck to ya! Carol

Thank You Anne and Carol. I appreciate your advice. I have already written a letter with all of my medical issues, and the treatment for those issues.. I listed the diets I have tried and failed at.. then I took it to my Gyn and she put it on her letterhead and signed it then faxed it to the surgeon. My file with the surgeon has all of the letters written both by me and my family members, as well as the Gyn referral letter stating medical necc for me.. but today when they went to fax everything to insurance this is the wall my insurance company threw up, so the surgeon's office decided not to send anything until we sort out this pre-existing stuff, so thats where I need help to know what to do.. I want to send what I have to, but I don't want to send something that may cause a problem with approval later. I know already without a doubt, that the clinic I have been going to for these last several years will in no way help me so I have to use the Gyn as my pcp, but that is a huge huge risk for me due to the lack of records.. IF I am asked for a 6 mth diet then I will do that, but if they turn me down because I could not afford to go to a doctor before now for a documented diet program, or try to say they wont look at my prequalification stuff because of some pre-existing clause , I think it will devestate me! I have tried very hard today and tonight to not get too down but I cant help it, this insurance really stinks so far and I am scared I will get denied even after jumping through these hoops. I have been at this for over 9 mths now. Every day is harder for me to get through and I am trying as best as I can to hold on and keep some hope, but it is seriously dimming in my heart. Dawn

Dawn, Wahat exactly is the ins wanting to have? Pre-exisiting what?Obesity? In my opinion...If the clinic wont help you then all you have is your gyn? She is already stated that you need the surgery. When my insurance turned me down twice it was for the six month diet deal.. NO and ifs or buts. My dr wrote a very similar letter stating all the diets I had done and how much i weighed each visit. It was not 6 consecutive months he also stated diet doesnt work for me... he has been my PCP for 7 years....The insurance then came back and said ok well now we want notes of the visits what kind of diet was discussed and exersise and medication for weight loss....then said it can not (6month diet history) can not be done by a wls surgeon.... so if you have to go through intracorp in anyway for pre certification this is what they want... Soooo did you call the insurance and ask what do they want exactly???i did not get that part...i understand they wont treat anything pre exsisting right?? If so sounds like you gotta wait til December...I know it seems like forever but it may in the long run get you approved for this surgery... If they say you are already obese then that is pre exsisting ...so they wont cover it...If you wait til december then you get to skip that part... I hope i have made some since here.... Michelle

Hi Dawn, I can understand your frustration. Medicare wants 3-5 years of medical records documenting my weight, blood pressure, check-ups, etc. The problem is I was going to the Veterans Hospital in Nashville and in West Virginia. They will not release my files to a civilian Dr. and if I request them for personal use, it's $3.00 per page. I don't have that kind of money, as I was seeing a variety of Dr.'s, the only thing they can't release is my mental health papers. Which I am glad about, it's no one's business what my mental health was like during that time. I was suicidal, having found my fiance in bed dead, after just one hour after seeing him. Yea, I cracked up, who wouldn't. But that's not me today, so past mental stays with the VA. So I am hoping that because it was thru a Veterans Hospital, they will just accept the records for the past year. Those I still need to get. I see my PCP on Thursday to sign a release so they can fax my files over to the surgeon. Frustration, I know it well. As for the insurance, honey, I don't know what to tell you, can you get a copy of your records from the clinic? Then you could mail them to the surgeon. You do everything possible to get approved. Yes, the insurance will say obesity is a pre existing condition. Well, shoot far, no kidding. It didn't happen over night, and it certainly didn't get there after Dec. 1? How long does the insurance say the pre existing condition has to be before they will cover the surgery? I would get copies of all medical records that you can get. Have them ready or in your surgeon's hands then when the insurance kicks in, the doc will already have everything needed. Best of luck Kathy