Question:
bariatric center says they verified coverage, insurance co denies verification

I have completed the mandatory requirements made by my insurance co. The bariatric center that I have been attending throughout this process says in the beginning of the program they verified coverage for the surgical procedure I am seeking. I was then denied by my insurance company, they informed me that any surgical procedure for morbid obesity was an exclusion and denied any verification from the bariatric center on my behalf. Does anyone have any suggestions?? I don't know where to turn. The bariatric center says they verified coverage, the insurance co denies any such verification. I would have never put myself through this process and all the emotions, had I not been assured of my insurance coverage in the very beginning.    — geegaw (posted on July 25, 2008)

July 25, 2008
Here's what happened to me...I have BCBS of TN. The insurance specialist at the weight loss center I chose called to confirm coverage before I started anything. She was told that my insurance would cover 100% if I met their requirements. Since they were willing to pay 100% I began fulfilling all their requirements. After going thru all the crap they put you thru in order to pay, I find out a few weeks before surgery that they only pay 50%. It seems that the BCBS customer service lady had given out false information in the beginning. I was VERY MAD! I would never have started this if I had known I would need to come up with half the money. Anyway, the insurance specialist had written down the name of the lady at BCBS that she spoke with that said they paid 100%. I then sent an e-mail to BCBS explaining what had happened. I explained to them that the only reason I went for the surgery was because I thought they paid 100%. Much to my surprise...BCBS investigated and listened to the taped recordings of the BCBS lady that had given the false info. Due to this phone call being recorded and them hearing that my doctor's office was given false info., BCBS agreed to pay 100% because it was their error. I was amazed!!!!!!!! So NEVER give up. I took this as a sign of fate that I was meant to have this surgery. So far...it has been a GREAT decision.
   — AprilJM

July 25, 2008

   — nursenut

July 25, 2008

   — nursenut

July 25, 2008
The same thing happened to me. What happened was my insurance plan covers it, but it is an exclusion my husbands company has, so they wouldn't pay it. I ended up having to wait till I was able to self pay and ended up getting a WLS that costs less, but the results are supposed to be up there with an RNY. I self paid for the Vertical Sleeve Gastrectomy (VSG). I took our a loan and has my VSG a little over a year ago (6 yrs after I started researching WLS because of not having the money) and am so thrilled I was able to have the surgery I had. It was a blessing to me that my insurance wouldn't pay. Now I don't have any mal absorption, not that it is a bad thing, it's just not right for. U have lost over 100% of my excess weight. Teresa
   — Teresa V.

July 25, 2008
Gayla, I am so sorry for the confusion. Unfortunately, there is only one answer to this question and you are not going to like it. I am an RN who used to work for the insurance industry and there is a notice in all Plan Handbooks that basically states, no matter what you are told over the phone, in writing or any other time, the terms of the Plan will always supercede... meaning that the coverage based on your Plan in the handbook is right. Their own employees can give out incorrect information on the phone, by fax or in writing, but it doesn't matter... the Plan benefits are always correct in the long run. You could try to appeal, you could get a lawyer and fight and you might be able to get something, but if it is a plan exclusion... chances are slim. I had BCBS of FL at the time of my WLS 2 years ago and all bariatric surgery was a plan exclusion. I was a self pay and would do it all again. So we completely depleted our savings, and it sure was a lot of money ($18,500) but a drop in the bucket to save my life. You do whatever you have to do to save your life, get a loan, borrow from friends/family, get a medical credit card... get it done if this is what you have decided you have to do to save your life. One positive note, self pays get surgery done very quickly.... cash in hand means no lines, no waiting!!! Good luck to you, Dawn Vickers, RN, BLC, CLC
   — DawnVic

July 25, 2008
Gayla, I had something similar happen the first time I tried to get Cigna to approve me 3 years ago. I finished all the requirements, but Cigna told my surgeon that WLS was excluded. Well our co. is self funded, Cigna only administers, and it was NOT EXCLUDED. Huge hassle, Cigna would not listen to me at all; basically they had it wrong in the computer. I finally got someone at Cigna (through our HR dept) who got it changed. So what I'm saying is this: 1. Know what your company's policy actually says. Call HR and get them to get it in writing. Yes, they are really busy, but they were happy to help me. 2. Don't give up; keep talking to people. Maybe it's a mistake and they will fix it. If it's actually excluded, then proably not. But until you know for sure, keep talking. Sara
   — Sara C.

July 26, 2008
Check with your HR people, they should have a copy of the actual "policy". I would have done this but the HR person was direct report to my husband, and well I did not want to share my problems with this person. This is my story and how I handled it myself; The surgeon's office called to verify my benefits and was told I had "none", I knew this was not so. I kept calling and pushing until it escallated to a supervisor who with my insistance looked into the companies plan, and sure enough I was covered for bariatric surgery, no rider. She sent requests to have my benefits entered correctly into the system. This takes awhile , and unfortunately twice again the surgeon's office was told I had no benefits. I was pretty frustrated so my husband who is the "insured" obtained the account manager's name and called her. She made sure that anyone who called was told that I had benefits and she also made call to the surgeon's office to inform them I was covered. As cigna is huge company and fixing the problem on one end does not mean it's fixed system wide! When claims for psych eval and surgeon office visits were denied I knew once again I would have to make the calls to get that fixed too. Each time I callled I would wait as the customer service rep read through all the notes from previos calls, they would send claims through again with special note "I have coverage" some claims it took 3 tries but the were paid. I fully expected once Surgeon's office requested approval for the surgery I would again need to fight for the benefits I have. This did not happen. the insurance company approved. Now, I will be ready after I have the surgery to fight for the coverage if my claims come up denied. Don't give up !!!! best wishes to you Gayla! Cathy
   — Cat C

July 27, 2008
The best thing I can recommend is that you take a copy of your policy, read every page, look for inclusions and exclusions. Go back and appeal that decision. As was said if you have not done keep the name time of day of the person you spoke to. There are also some Lawyers out there who might be able to help. It does not help much, but this is very common. The insurance companies are not in the business to pay claims.
   — Ira Sansolo