Question:
Can someone please help me with the struggle of appealing my Blue Cross denial?
My surgeon's office (Dr. Higa) has been NO help whatsoever. I had to call Blue Cross myself to get a copy of the denial letter and when I called Dr. Higa's office to speak with him to ask his recommendation on how to approach the appeal, I was told that he does not deal with the insurance. If I want to appeal the decision I have to figure that out myself. Any help is greatly appreciated; I am incredibly frustrated, depressed and feel like I am fighting this all on my own. Thank you, Alda Hearne — Alda (posted on February 24, 2009)
February 24, 2009
Find another surgeon. One that will help with all the paper work. My
surgeons office did everything and I hav federal blue cross and was
approved in three weeks. I am in New Orleans, LA but I know for sure there
are other doctors that care enough to help.
— saints1
February 24, 2009
Before people can be helpful, we will need to know what reason gave you for
refusing to cover the surgery? Knowing what State are you in can also help
with what resources may be available to you.
Best wishes!
— nursenut
February 24, 2009
Hi, I work for Anthem Blue Cross. They now have 'Centers of Excellence'
for bariatric surgery- this is a new program and benefit for 2009. Call
the customer service number on the back of your insurance card and ask the
cs rep to enroll you in the Bariatric Program. They will transfer you to
the transplant program reps(weird, I know) and you can leave a msg. They
will return your call within a day or so, depending on their call volume.
They have the new Centers of Excellence throughout the US and it is my
understanding that the out of pocket expense is a set amount. Good luck!
— amanda_g
February 24, 2009
Find another surgeon with competent and professional office staff. You
also have the right to report them to the ethics committee. I would also
keep an attorney in mind. You might also find an attorney who deals with
situations like yours.
vinnigirl, retired RN
— vinnigirl
February 24, 2009
Really all insurance is different from state to state. One piece of advice
I will give you is find out if your company has a different set of rules
when it comes to WLS...mine did and it was alot easier than BCBSIL...and
once I found that out and knew what I was talking about I was approved in a
week. I do agree though find another doctor....mine did everything for me
all I had to do was show up when and where they told me to for classes,
tests etc. Good Luck! Donna
— gonnabethinfinally
February 24, 2009
I agree with the answer above me... Call the # on the back of your
insurance card & see what stipulations they have on wls .... It makes
a difference which policy you have.. I know Blue Cross Blue Shield of
Texas does not cover wls at all for any reason. Or they didn't a year ago
when I was trying to get everything ready.. I had to get all the denial
letters from them and then file on my secondary insurance, which is Tri
Care Prime. Sometimes it takes a lot of paper trails but it is all worth
it. And it also helps tremendously if your doctor is on your side and
helps you out. Good luck and I hope things go well for you!!
— stylinjanet
February 25, 2009
Hi Alda, i feel for you my dear. I have Wellmark BC/BS and i am also in
the same surgeons office as you,Dr Nimeri (wonderful man) anyways i was
also denied due to no proof of medically supervised weight loss. When i
received my denial letter i called my rep at the Dr's office, she asked
that i fax her a copy of my letter as she had not received any notification
yet. We discussed the reason why and she said i needed to contact my
primary physician who supervised my weight loss, and get copies of all the
information i could to send to the insurance company with the appealletter
and appeal sheet, i was told by my Rep what i needed to include in the
letter. It really wasn't that hard to do actually,just time consuming. i
searched on OH and asked questions on here also as to how to do a letter of
appeal, everyone was very helpful.
I sent my letter of appeal to the insurance company on the 16th of this
month, i called Monday and was told that it was in for clinical review
which could take up to 4 months..grrrrr.. anyways.. it is all a waiting
game...if i am denied again...well i will just keep plugging along until i
exhaust all avenues or they get so sick of me that they approve me.
"smile" It is not the end of the world, just dispointing and
extremely frustrating, especially when you have a friend who started her
process after you did, (she didn't have anything really medically wrong
with her) she gets approved right away and is now 3 months out from her
surgery...don't get me wrong, i am very happy for her but am disappointed
for myself. anyways if you need to talk more or just want some moral
support give me a jingle at
[email protected] i will be more that happy to help all i can. Chin
up!!!! things will work out
— Grace M.
February 25, 2009
I was denied from BC/BS PPO due to no documentation of 6 months weight loss
history. I typed my own appeal and went to every doctor that has ever
given me diet pills and got copies of the medical records and copied all my
weight watchers record books and faxed a 35 page appeal and was approved
the next day. I just kept calling and did everything myself.
— vicki0409
February 25, 2009
Sorry to hear your going so much, but I was there only my doctors was in my
corner in getting this done. In your case your doctor don't seen to really
care one way or another. Because when you explain to him or her what has
happen he or she could have has the office manager type a letter explained
the medical reason for the need for this surgery and attached all necessary
paper work. There certain forms that have be fill out, there guideline that
must be following and completed in a certain amount time if not this will
get it rejected, if there type error this will get it rejected, if the
doctors submitted the correct information or answer all the questions right
this will get it rejected. There a many of things did the insurance tell
you why it was rejected? and I tell you something as long as you are taking
the diet pills this a right to denied due to the insurance is waited to see
if the pills work this save thousands of dollars. You need to email me and
I work with you regard this matter. Once rejected myself
— TR042108
February 25, 2009
Find another doc who will work with you on your insurance. The staff of
the surgeon I see took care of all of the paperwork. I showed up for appts
and the surgery. There are plenty of good surgeons who have a work ethic
and whose staff are trained to handle the insurance. Just be thankful that
you found out what kind of "doctor" he is before having the
surgery.
— Dawn A.
February 25, 2009
I second Amanda's suggestion (the one who works for Anthem Blue Cross). My
surgeon is Dr. Michael Snyder in Denver; he participates in the
"Center for Excellence" program and I can tell you, EVERYONE who
works for him takes that distinction VERY seriously! They bend over
backwards to be helpful, respond to all questions promptly, and help
resolve problems quickly. Good luck and God bless! Julie Preston, RN
— MuseAcal
February 28, 2009
I went through the LIVLITE program and they handled everything for me
including the denial and getting approved here is their web site
www.liv-lite.com They have surgeons in different places Mine was in Kansas
— mystic0619
March 1, 2009
You've been given the best advice that I could think of already but I'm
going to say it just the same. Find a surgeon that isn't too cheap to have
adequate staffing. One that provides support before and after surgery.
The changes that come with the weight loss are many and we can all use
someone to talk to who knows what we're talking about. OH.com is a great
place to blog but I can't see you online. I rather see someone during a
conversation and support groups help because you can see the changes others
are going thru too. Find a surgeon who will give you what you need to
succeed! Thoughts and prayers. Gail Gore
— Gail G.
March 1, 2009
Hi Alda... don't get discouraged. You need to find a surgeon that
specializes in Bariatric surgery. The marjority have a support system in
place to help you out. Also, I have some other suggestions for you, in
addition to the phone number on your card. There is the American Society
for Bariatric Surgeons (352-331-4900 / asbs.org), American Obesity
Organization (obesity.org) For finding a surgeon in your area.. American
Soc of Bar.Surgeons (see above) There are sample appeal letters in the
following book, which you can check out at the library; "Gastric
Bypass Surgery" by Mary P McGowan, MD (ISBN: 0071431926, $14.95)(I
bought some books prior to surgery and still refer back to them
periodically for myself as well as for others. There are all kinds of
reasons for the denial.. you need to know the reason so it can be
addressed. Sometimes, things in the original letter from the surgeon are
mistated or incorrect, you can be sure that they are corrected. Sometimes,
there has not been an established (on paper)previous attempts at weight
loss. These are only a couple of the many possible reasons. And, there may
be more than one. But, when you find it out, then you can address it. If
it is still unclear, then call the insurance company and ask to speak with
someone for specifics. Keep your chin up and don't give up, it will be
worth it in the end. Good luck... Kari K
— Kari_K
March 3, 2009
Hi, I was just recently denied too. I was getting info prepared for an
appeal. My primary physician wanted to know whom he needed to address his
letter. I called the number on my denial letter. This is when I found out
I could ask for a PCR (Provider Courtesy Review). If that didn't work, I
could still go through the appeal process. I faxed my letter, my doctors
letter, and another weight loss document, and within the week, I got a fax
that I was approved. Most are not aware of the Provider Courtesy Review.
— P M.
March 3, 2009
Hi Alda I also am a patient of Dr.Higa.I was also denied and they won't
help me either.I am going to try another surgeon in my area that will help
me with the process.I have Anthem blue cross nd was denied because I don't
have any medical problems just overweight.
— cdisanti
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