Question:
Which is easiest for approval, HMO, PPO, or EPO?
I am currently in the process of having new insurance coverage, but now the decision is if I should choose our HMO, PPO, or EPO plan. Cigna is the named provider for the HMO and PPO (and I have heard horror stories about them) and Aetna is named as the Epo. Anyone have any advice?? — MiChelle V. (posted on January 23, 2003)
January 23, 2003
I have Aetna EPO and was approved on first try. They really are a great
company to work with (at least the people that deal with our employer).
Just remember to have EVERYTHING in writing.. get copies of every medical
record you can find.. you will need 5 yrs of documented morbid obesity,
history of failed diet/exercise attempts (get receipts, contracts from
gyms, etc), you will need at least a 6 mo doctor supervised diet within the
two previous years (and it must be in your medical record, not just a
summary letter from a doc), a BMI of at least 40 or a BMI of 35 plus at
least 2 comorbids.. Aetna is all about checking off lists.. so if they are
able to check off all of their little boxes you will be approved. Make sure
you have everything they are looking for and you should have no problem.
Visit this link and you will see what they want.
http://www.aetna.com/cpb/data/CPBA0157.html
Good luck!! .. Sarah, surgery date 2.3.03
— SarahC
January 23, 2003
You should be able to find out before you have to choose whether these
plans cover WLS. It really doesn't matter as far as HMO, PPO or EPO. All
of those can approve the surgery and all can also deny. It depends a lot
more on the insurance coverage itself, your employer and sometimes which
state you are in. Insurance plans differ from state to state and from one
employer to another. If your employer has specifically asked that WLS not
be covered, then it would be an exclusion. It might also be that your
employer has specifically asked for it to be covered. The only way to know
for sure is to ask your HR Department and/or the customer service people at
both Cigna and Aetna.
— garw
January 23, 2003
hi there :) first of all id like to wish you the best of luck in finding
the right insurance for you! :) im ganna agree with gar in that it really
depends on alot of different things as to which will or willnot cover wls.
personally, i had bcbs hmo of illinois and they were absolutely wonderful
about the entire thing! i only waited one week for approval for my surgery,
yes , that was the longest week in the history of my life LOL but i was
very pleased. the only thing that didnt have me to happy was the fact that
i was able to see surgeon at 2 weeks post op, and 5 weeks post op but
beyond that, ive not been approved to see him since which is not good in my
opinion.i really wanted to be able to follow up with him so he could see my
progress and the fact that he knows a whole lot more about wls than my pcp
does. oh well! needed to vent a little :) and again best of luck to you! :)
— carrie M.
January 24, 2003
I had Cigna EPP when I got approved. It took 5 months however to get
approved. Start now making sure all your ducks are in a row. If you
don't have 12 weeks of physician supervised dieting (my doc gave me a diet
plan and I weighed in once a month) get started now. They don't always
back down from that one. Make sure your doctor's notes have record of all
your co-morbidities. If you're 100 lbs. overweight, have multiple
co-morbidities, make sure it's all documented and get those records so they
can be submitted to the insurance when they try to get your approval for
you. The longer you delay, the longer it will take for approval. I
changed to Cigna PPO this year because I didn't want to take the chance of
delays if I needed something or decided I wanted to have skin removal.
I've heard it's easier with PPO, but should be doable with any of them.
— Cathy S.
January 24, 2003
Hi
I have a PPO and they said yes first go round. I never had one bit of
trouble with them. Now we shall see what happens when I ask for approval
with plastic surgery!! Best wishes.
— Gina D.
January 24, 2003
Hi MiChelle for me it was the PPO, my Dr office did it all and I was
approved in 5 days Blue Cross of California. Hope this helps, the Dr office
did tell me that they had to make sure all the paper work was turned in
with the request or it could get held up.
— tonyskid
January 25, 2003
First of all as the previous poster said..all can approval/deny easy or
difficult. It depends really on the SPECIFIC person that is handling the
approval...remember they are people too and have their good and bad
days...not to mention if they are short on staff or busy that time of year.
I applaud your company for offering a variety of plans. The main difference
in the plan types is whether you can self-refer in network or out of
network or if you must go thru a PCP for referrals. PPO will tend to cost
more in the end (deductible, copay, and your contribution via payroll).
Choosing an insurance based on approval/denial is not the best way to
choose especially if you have other members on your policy or are on a
tight budget, ok..enough of the preaching {I've worked in health insurance
too long, sorry *smile*) I have a friend who went to work for a company
just for their insurance plan. She wanted the surgery and asked the Dr who
is the best for approving/paying for the surgery (we live in
California)they told her Aetna was the best. If you want more information
on the plans, feel free to email me.
— Robin J.
January 26, 2003
Hi, just wanted to say that I have Blue Shield HMO and was approved within
a week. Remember that when you have an HMO, your approval is coming from
your medical group not from the actual insurance company. But you do have
to make sure WLS is covered. And the most important thing to remember is
that with an HMO, everyting is covered 100%. Surgeon, Asst. Surgeon,
Anesthesiologist, labs, etc. Good luck.
— Audra P.
January 26, 2003
I know some people say it's easier to get approved with a PPO, but I got
approved within a day with Blue Cross HMO. My company switched to Blue
Cross PPO in January and I'm SO glad that I had my operation when we still
had the HMO. The co-pays are higher now, and I would have had to pay a
percentage of the costs for the operation, whereas I paid $0 for it on the
HMO. I don't know anything specifically about Aetna and Cigna, but I
wouldn't automatically assume that a PPO will provide more assurance of
approval than an HMO. Many, many people have had this operation via HMO
insurance.
— sandsonik
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