Question:
Need your input. Should I spend the money on an appeal or save toward self pay?
I am in my first appeal stage against an exclusion that is very specific to gastric bypass, etc. My pcp is willing to appeal however will be charging me $160.00 per hour for his time. He says in his experience,appeals for exclusion with my insurance company only get approved about 25% of the time and he has never done one for WLS. I have limited resources. Should I try for the appeal or save the money toward self-pay. I am torn. Would appreciate any and all opinions. Thanks — cheryl R. (posted on October 5, 2000)
October 5, 2000
Depending on your ins. comp.and the exclusion, I would talk to Walt @
www.obesitylaw.com
— Michael (pokie) F.
October 5, 2000
Your question really made me appreciate my PCP. I was shocked to hear that
your PCP wanted to charge you for his time by the hour. Mine went to bat
for me so many times but without success. I even hired Walter Lindstrom
and in my own personal opinion, I would not recommend him. I know he has
helped others but my experience with him left a lot to be desired and I
spent $750.00. I am finally able to get other insurance because of being
self employed and they will pay with no preapproval process. The only draw
back is that I may have to wait a six month waiting period before I can
have the surgery. I guess what I am saying is, if you are going to spend
the money on a lawyer or your doctor helping you, don't go into it
expecting an approval like I did, because I was sorely disappointed. I am
not trying to be doom and gloom here but just being realistic from my
experience.
— [Anonymous]
October 5, 2000
I would not pay a PCP $160.00 for help with an appeal. What about your
surgeon? My surgeon is appealing my case on my behalf. All I had to do is
write a letter asking them to file an appeal on my behalf & why I
wanted to appeal. If you want to do it your self research & research,
is my best advice. Get a copy of your medical records. See if your PCP will
write you a letter stating you need this surgery. He probally won't if he's
charging you for help with an appeal. But it wouldn't hurt to ask. My pcp
has written 2 for me, free of charge. I wouldn't pay anyone when you can
get someone to help you for free!
— [Anonymous]
October 5, 2000
I hope I'm not out of line here, but how about finding a new PCP? It
sounds like the one you have now isn't really patient oriented. Most PCP's
wouldn't hesitate to draft up the paperwork needed to submit. If you
already have a surgeon I would go through him. If not, I would think about
shopping around for a new PCP, maybe someone who has dealt with the WLS
exclusion before.
— [Anonymous]
October 5, 2000
FIRST--If you have not gone to a local support group, do that. Had I gone
to a support group I would have had the names of many Drs in my insurance
system that favor wls for their morbidly obese Patients, and have
sucessfully provided the needed referrals and tests. I did not do this, and
so far I have paid nearly $20,000.00 out of pocket.
SECOND--Do lots more research before paying an hourly rate to a dr. when
you can't verify the hours he has worked for you.
THIRD--Remember the doctor works for you, and you can fire him. My PCP is
fired.
— Cara S.
November 10, 2001
I also had a contract exclusion on my BC/BS PPO policy. I did have a
gallbladder ultrasound that showed it was diseased..so surgery was
recommended by my PCP. So, BC/BS will pay for the gallbladder portion and I
will self-pay the rest (about half) it was the best I could do to get this
surgery. Luckily, my surgeon was in-network.
— Cheri W.
July 14, 2003
Contact me about Care Entree. [email protected]
— Calie F.
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