Finally got approved..a.k.a. Its been a long time - Tips for PEIA/Newcomers
Hello Fellow Members, 
I haven't posted recently since I have been struggling with my insurance company. My rants were annoying, even me. In any case, its been 20 LONG months but I finally got approved.
My surgical date is scheduled for January 8th 2007. Dr. Robert Shin (CAMC) will do the honors.
In case anyone has forgotten me... my issues:
I, like many others, have been told by my PCP's to lose weight, exercise more, bla bla bla. They set me up on diet plans, exercise, ect... which I assumed ( and you know what they say when one assumes...) was being documented on my medical record.
Well, they weren't documenting. At least MY PCP's weren't.
So, when I went to Dr. Shin's seminar in April 2004, I thought, this could be a literal "piece of cake", since my last 10 yrs with my former PCP has been one weight related issue after another.
Not so.
When I finally got copies of my medical records ( which my former PCP charged me for... with fees for the person to print them out ) my records did NOT show documentation of diet related material. Even the meds prescribed for me were missing. Odd? I thought so. But I applied anyway.
And, I was turned down by my insurance company, Acordia PEIA. They specify 12 months of detailed documentation. They also want it worded a certain way.
Since they ( insurance ) couldn't use my previous records, and by then, I had asked my former PCP about their thoughts on Gastric Bypass Surgery ( which they refused to support me ) I needed to make a decision regarding my PCP. I needed a provider that was willing to work with me before, during and especially after.
After asking other members of this board, a new PCP was recommended.
After interviewing and accepting this new PCP, I prepared to get documentation. But even with a great PCP, I still had one issue to deal with... and my insurance company nit-picked it constantly.
See, my new PCP wanted me to journal and come in for bi-monthly weigh in's. I am not much of a blogger, diary or journal. Never have been. And, I simply didn't have the time to wait in the PCP's office to have them get my chart, find a nurse and document.
I didn't see this as being a problem since this isn't specifically noted in Acordia's
terms. Well, I was so wrong! Evidently, if the PCP says part of your plan is to journal, then you MUST journal. If they say jump, you MUST jump. Acordia is really specific with their terms.
Of course, I didn't realize this until I applied and got denied AGAIN.
So, in early spring of 2006, I began journaling like a son-of-a-gun. I did exactly what they were looking for. My last denial letter said I could re-apply "at the end of the year" which I translated as Mid-November.
So, the first of November 2006, I re-applied.
And wouldn't you know...my PCP didn't submit my weigh in! Could this get any worse?
By now, I filed an appeal, which ended up at the Capital. They had their medical directors evaluate my application and they agreed that I had cooperated BUT they still needed more documentation.
I immediately contacted my PCP and they had medical records fax a copy of my weigh ins to the Medical directors. With the holidays in November and the fact that the Medical Director is only in on certain Tuesdays... I was definitely not a happy person.
But it finally happened. All the stars aligned up for me and I got the phone call. Within a few days, I got the letter.
I was finally approved.
Hallelujah!
So, I got my Christmas wish early. I decided ( now that this is back in my control ) that I would wait until after the Holidays to begin my new journey.
If anyone needs specifics, please feel free to contact me. If you're a newcomer and/or are fighting with Acordia, I can give you names, numbers and suggestions.
If there is one thing that I can say, now that I am on "this side" of the situation, be patient. Follow the rules, tell your PCPs what they need to document. Some will be apprehensive because they don't like being told what to document. But let them know its nothing personal, its insurance related. Find a good surgeon, who's office staff will assist you completely ( for me, Dr. Shin's Office, in particular ) and don't be afraid to ask others who have experienced the similar issues.
And one final thought...... I deeply believe that things happen for a reason. As much as I went through the frustration and aggravation of dealing with denial after denial, I believe that things happen when the timing is right. For whatever reason, the timing wasn't right for me. Yes, I can say that NOW but it was the only thing that kept me going these last 20 months. It was the ONLY thing.
So, I begin the newest chapter of my life history. Although I feel the worst has been overcome, the best will be the real test. And I am ready.
Merry Christmas and Happy Hanukkah everyone. And may you all have a spectacular new year where all your wishes come true.
Jen
I haven't posted recently since I have been struggling with my insurance company. My rants were annoying, even me. In any case, its been 20 LONG months but I finally got approved.
My surgical date is scheduled for January 8th 2007. Dr. Robert Shin (CAMC) will do the honors.
In case anyone has forgotten me... my issues:
I, like many others, have been told by my PCP's to lose weight, exercise more, bla bla bla. They set me up on diet plans, exercise, ect... which I assumed ( and you know what they say when one assumes...) was being documented on my medical record.
Well, they weren't documenting. At least MY PCP's weren't.
So, when I went to Dr. Shin's seminar in April 2004, I thought, this could be a literal "piece of cake", since my last 10 yrs with my former PCP has been one weight related issue after another.
Not so.
When I finally got copies of my medical records ( which my former PCP charged me for... with fees for the person to print them out ) my records did NOT show documentation of diet related material. Even the meds prescribed for me were missing. Odd? I thought so. But I applied anyway.
And, I was turned down by my insurance company, Acordia PEIA. They specify 12 months of detailed documentation. They also want it worded a certain way.
Since they ( insurance ) couldn't use my previous records, and by then, I had asked my former PCP about their thoughts on Gastric Bypass Surgery ( which they refused to support me ) I needed to make a decision regarding my PCP. I needed a provider that was willing to work with me before, during and especially after.
After asking other members of this board, a new PCP was recommended.
After interviewing and accepting this new PCP, I prepared to get documentation. But even with a great PCP, I still had one issue to deal with... and my insurance company nit-picked it constantly.
See, my new PCP wanted me to journal and come in for bi-monthly weigh in's. I am not much of a blogger, diary or journal. Never have been. And, I simply didn't have the time to wait in the PCP's office to have them get my chart, find a nurse and document.
I didn't see this as being a problem since this isn't specifically noted in Acordia's
terms. Well, I was so wrong! Evidently, if the PCP says part of your plan is to journal, then you MUST journal. If they say jump, you MUST jump. Acordia is really specific with their terms.
Of course, I didn't realize this until I applied and got denied AGAIN.
So, in early spring of 2006, I began journaling like a son-of-a-gun. I did exactly what they were looking for. My last denial letter said I could re-apply "at the end of the year" which I translated as Mid-November.
So, the first of November 2006, I re-applied.
And wouldn't you know...my PCP didn't submit my weigh in! Could this get any worse?
By now, I filed an appeal, which ended up at the Capital. They had their medical directors evaluate my application and they agreed that I had cooperated BUT they still needed more documentation.
I immediately contacted my PCP and they had medical records fax a copy of my weigh ins to the Medical directors. With the holidays in November and the fact that the Medical Director is only in on certain Tuesdays... I was definitely not a happy person.
But it finally happened. All the stars aligned up for me and I got the phone call. Within a few days, I got the letter.
I was finally approved.
Hallelujah!
So, I got my Christmas wish early. I decided ( now that this is back in my control ) that I would wait until after the Holidays to begin my new journey.
If anyone needs specifics, please feel free to contact me. If you're a newcomer and/or are fighting with Acordia, I can give you names, numbers and suggestions.
If there is one thing that I can say, now that I am on "this side" of the situation, be patient. Follow the rules, tell your PCPs what they need to document. Some will be apprehensive because they don't like being told what to document. But let them know its nothing personal, its insurance related. Find a good surgeon, who's office staff will assist you completely ( for me, Dr. Shin's Office, in particular ) and don't be afraid to ask others who have experienced the similar issues.
And one final thought...... I deeply believe that things happen for a reason. As much as I went through the frustration and aggravation of dealing with denial after denial, I believe that things happen when the timing is right. For whatever reason, the timing wasn't right for me. Yes, I can say that NOW but it was the only thing that kept me going these last 20 months. It was the ONLY thing.
So, I begin the newest chapter of my life history. Although I feel the worst has been overcome, the best will be the real test. And I am ready.
Merry Christmas and Happy Hanukkah everyone. And may you all have a spectacular new year where all your wishes come true.
Jen Most Active
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