insurance or common sense help?

So, this whole process has been more than frustrating for me. I'm kinda a driven, direct, get-to-the-point kind of person, and the waiting and the ambiguity of this has been upsetting. Basically, I've gone through all the pre-op tests and now my doctor is waiting on my previous doctor records to submit my request to insurance. I have United Healthcare. my three issues are this: 1. My doctor said that we're still shooting for surgery this summer, and told me if I haven't heard from the insurance 4 weeks before I want the procedure done, to email him. He said that considering I'm a student, "highly motivated" and having surgery over the summer makes sense, the insurance will probably work with us. I'm like- on what planet? I've never heard of an insurance company that cares about "working with" the insured. Ever. 2. If my insurance covers my surgery (which no one seems to know) they will most likely require 4-6 months of medically supervised dieting. My doctors assistant tells me that I'm already doing this, because I have met with a nutritionist, and I just have to follow up once a month. However, this nutritionist isn't a doctor (hence, the medical supervision) and she didn't even put me on a diet, she only explained my post-op diet. I don't yet have a PCP in miami, and it just angers me so much that I might have wasted all that time when I could have been legitimately doing whatever the insurance requires of me. I just think that there is a huge disconnect between what my doctor/doctor's office is saying and what everyone else seems to be saying, and I don't have any idea why they wouldn't know that kind of information. I feel like either I'm being way too cynical and worrying for nothing, or the doctor's office is really clueless about a lot of this (he is new to the area, and the hospital, but insurance issues? that seems like it would be most of the battle for most patients) any insights?

First let me say good luck!! Have you called UHC? They were VERY upfront with me about what they covered/ didn't.  UHC has MANY different plans some pay, some don't. UHC is my primary. My plan will pay for all pre and post opt testing adn appointments, and hospital stay but not my actually suregery. I do have a secondary insuracne that will be picking up the rest of my bill. I will tell you I had the approval letter from UHC, within 3 days from the written request. I provide very little info to them. (I submitted myself, and I just sent medical records for two years) I have been told since I have a secondary insurance it was much easlier.  But my doctors office will be submitting to my secondary insruance next week for me, they wanted every test known to man kind!

All you need to do to find out if insurance covers your surgery is to call - you can also contact the HR dept who handles your insurance (if its thru an employer) and ask for a copy of the benefits book, it will be there.... UHC, I assume, has online access for its members and possibly your benefits information is online as well. Typically a surgeons office calls the insurance FIRST THING to verify benefits - why waste their and your time to find out the procedure isnt covered? Also the insurance company, if they cover, can tell you over the phone *ALL* the requirements to have WLS, including if a pre-op diet is required. The Drs office does seem clueless to me - do they deal with other UHC patients? Typically surgeons offices know the in-and-outs of the insurance companies because they work with them each day. As for the insurance company approval process - there are different laws in different states, typically they have 30 (sometimes up to 45) days to review the initial request, they can also tell you what their approval/appeal process is over the phone. You dont need to email your surgeon if you dont hear, you can simply call the insurance company yourself to check status. As for the insurance company 'working with' you... you submit, they review... thats about it - they have their processes, they arnt going to 'rush' because you are a student... your surgeons office is the one who needs to get on the ball so you can get your stuff submitted.

thanks for the info. my mom actually called them and they said that it wasn't covered, but my father said that he had read under their statements of benefits that it was, so they're all sorting it out right now. If they would pick up all additional expenses just not the surgery, that would totally be doable. I do wish my doctors office wasn't so clueless, but this info has helped a lot

Its always under the not covered section of benefits - what you need are the magic words "unless medically necessary"... call back and ask again and have them read the ENTIRE benefit... it should be a paragraph... listen for those words, and ask to double check. Even if it is not covered you can still submit and appeal to see if you can get it covered, you could also consider contacting a laywer and enlisting their help. Your father could also talk to HR about it, sometimes they have a say in what claims are paid and what arnt, just depends on how the plan is set up. Typically if the procedure isnt covered, anything related to the procedure isnt covered - office visits, testing, hospital etc... you would be looking to pay everything OOP.

Jennifer said the same thing my doctors office said. Typically they do not cover part and not all!  It was my hubbys employer had thier plan wrote up. That is why. My doctors office said this was the first time they seen it. But UHC was great to answer the questions I had!