Last Minute Insurance Approval Reversal

Hi all,
I was scheduled for RNY on June 27 after completing 6 months of diet, fitness, documentation, etc.  My insurance company approved me for surgery and I completed all the pre-op testing, orientation, follow up planning, etc. last Friday. 

My insurance had given the go ahead in January 2011 and final approval code for the RNY on June22.  Late Friday afternoon  (before a Monday am surgery, me staying at a hotel away from home),  the insurance company called me to say that they had denied my case.  The reason given was that my provider/hospital is not on their list of Centers of Excellence and as such, my case was denied.   You can imagine this was a major surprise and disappointment. 

I am a patient at the Duke Center for Metabolic and Weight Loss Surgery which is rated a Center of Excellence by ASBMS.  We were all astounded - basically my insurance company gave an approval in error and then revoked it at the last minute.  Instead of admitting their mistake, they  first denied that they ever received my files, etc.  My team spent the weekend and yesterday trying to figure out the problem with my doctor even offering to contribute his fee to help the process.  

I was told by my insurance company that I am not denied the procedure - I could get a new surgeon tomorrow at a center of excellence on their list or appeal.  Regardless - I could not have the surgery and had to fly home today.  I am not sure yet if I have to change progrrams (or insurance companies but now I want them to pay in more ways than one!) or when I can move ahead. 

I posted this as I don't want this to happen to anyone else - even with an approval is it best to double check if the program is on the approved list of the insurance company.  I am not sure if this would have helped me as getting the approval code and instructions from the insurance company certainly seemed adequate.  My insurance company is United Healthcare - suggest if you can - avoid them.

Has anything like this happened to anyone in the group?  Ddi you have to switch programs/surgeons and if so, was it easy, did you have to repeat anything, etc.? 

This has been difficult - and emotional eating is one of my things to fix!  Hopefully I will bounce back quickly and am able to schedule the surgery soon.  I suppose the good news is that I will feel okay over the July 4th holiday. 

Thanks for any feedback on my questions.

Wow, that sucks. Check if there are any local surgeon's that are on their list of approved providers. I am sorry that you got this disappointment. The pre op things have been done, you have the documented 6 month dietician appointments. Appeal, find another surgeon, just do not give up. I have heard of this a time or two, and think that it is just not right. The insurance companies have waaaaaay to much control over our health care decisions. Know that we are here in your corner, rooting for your success. Do no give up.

Yup sucks big time.   Thanks for your kind words.  I was really upset last Friday when the insurance co called and then all weekend til today waiting while the team tried to work it out.  I will find another approved program or another insurance company but will raise heck with my company as this is just inexcusable - the insurance co screwed up and then tried to cover it up.  It was tough to come home now that the word has gotten out to friends and family (a small town, did not tell anyone until just before I left) but will be fine after I have a bit of re-group time.   Does make me want to become an advocate - insurance co's have too much control and I think there must be many worse stories out there than mine...at least I am not completely denied; it is approved just not with my team.  At least that is the story they are telling me...you never know until the end!   Take care!!

Dear Kathy,

    I feel your pain. I can't believe you are going through this too. I first tried to get my surgery done, but my insurance didn't even know their own policy on it. I ran off about 50 pages of info from the main website about requirements for the WLS. I waited a while because one of the local hospitals was working on becoming a Center of Excellence. My insurance at the time was backed by United Health Care. (HMO) Finally I got tired of waiting and changed to a different form of the same insurance and it went like clockwork. Please PM me so we can talk a little more about specifics.  Sorry you are going through this. Another hospital became a center of Excellence in our town and I didn't have to travel to have my surgery so the wait was worth it.    Mag   

Dear Mag,
Thanks for your encouragement!  I will pm you in a bit...now am just thinking and trying to calm down and regroup.  Will be okay but a couple days may help. 

My insurance is also United Health Care but not an HMO.  I could completely change my insurance company but I think this would mean a long delay so will investigate options that are on their "excellence"list.  I am not sure their list really means excellent but let's see.  Maybe something closer to home will be better in the long run....i am trying to think there was a bigger reason for this like the universe knew my surgeon would be tired this week:)
Take care!!! 
Hugs!

I strongly encourage you not to even try to change insurances at this point. It would result in a huge delay if not denial possibly. I would recommend locating a surgeon on thier list seeing who will take you the fastest, and getting it done. Then think of changing. I also recommend asking the wls doc you were going to have it through to provide you with ALL documentation on all of the pre-op stuff you did, as a new doc will have to have all of it to submit for approval.

I am so sorry you have to go through this. What a kick in the head! I would be livid! My heart is with you. Just do all you can asap and get it done while the getting is good girl. Hang in there, and DO NOT let them win this battle!

Thanks so much Patrece....you are probably right, changing insurance would be a  mistake.  I am now in waiting mode after getting my head back in the right space to fight it.  I have requested a formal review and also a waiver from my company on the limitation which they are in process of assessing.  I have to say this is very stressful - i also looked into getting a new surgeon / program but they all seem to  require starting from scrat*****luding the initial information session!!  And assessments by their nutritionists, behavior etc. so will take about 6 months - like doing it all again.  I am livid as this could all have been avoided if the insurance company had not given the go ahead in the first place grrr.  They will not win - I will keep on pushing!! Just hope others double check if there are any restrictions despite what they are told to avoid the last minute surprise!  Take care! 
Hugs,
Kathy

Kathy, Stand strong  and never give up! Maybe you could give the insurance company an incentive to approve since they will have to pay for doing all of these visits and reuirements over again??? Keep us posted!