Question:
Is there any way to bypass self funded insurance ref surgery

I work for the City of Ft Worth and our insurance is "self funded" therefore we would have to get approval from city council to provide for bariatric surgery. I don't know anyone who has gotten around that. Is it possible? Has anyone else had this experience. I'm by no means destitute, but with my house payment and other bills, I can't afford to pay for the surgery, but due to sleep apnea and diabetes, I feel I really need it. Is there any way to get any financial assistance? Please let me know. thanks    — Donna W. (posted on January 13, 2005)

January 12, 2005
I cannot speak for the City of Fort Worth but normally a self-funded policy has someone, other than the employer, administering the policy. It would be that group that you would work with. Only if they would keep denying you or if your policy has an iron clad exclusion would your employer have to be involved. If they do need to get involved I'm not sure it would really take a city council action, but I could be wrong. <p>I work for the State of WI and the policy I have also is self-funded. BCBS is hired to administer it. However if BCBS deny's me and I go through their appeal process and the claims/request still are denied then I can appeal the decision to the Department of Employee Trust Funds which is the State agency that handles all the insurance stuff. I've had to do this once, but was successful in getting the claims paid. It wasn't related to my WLS. We have about 4 insurance options available to us. 3 are HMO's and the one I have is now a PPO, it used to be a POS (Point of Service). The PPO is the only one that will cover WLS, cut and dried, and they make it clear when we go through open enrollment each year that this is the case. So appealing the denial with one of the HMO's won't get you anywhere in our case. The bottom line is if you need the surgery you need to fork out the bucks for the higher cost policy. As a single person I would have paid $50 per month for the HMO my docs are covered under and I paid $100 for the POS, so it's not a huge difference. Under the family policy it took a huge jump. I would pay $100 with the HMO but the POS costs me $250 per month, but thruthfully to have access to any doctor I want, and without a referral, it is worth it to me. If I stay in-network then I only have a $100 deductible for the year and 2 per family. If I chose to go out-of-network I have a $500 deductible and then 20% co-pay till I reach a total of $2000 paid out, 2 per family. This is actually what it was when it was a POS contract. So going to the PPO actually saved me tons of money. So make sure there aren't some insurance options available to you also. Good Luck!
   — zoedogcbr

January 12, 2005
The "self-funded" thing actually worked to my benefit. Aetna denied me and I spent hours on the phone trying to talk to anyone who had the ability to make an approval decision. Finally, it was turned over to my husband's company. I made one phone call (to some very nice people) and they told me that they were meeting the next day to discuss ME. After that meeting, I got a call saying I was approved!!!! (from my hubby's company) I think it was an easy decision for them as Aetna had been spending SO much money (paid by my hubby's company) on me and my medical issues! Dont give up! Leslie -92 pounds
   — leslee4567

January 12, 2005
On a self funded policy, the employer ALWAYS has the right to overturn the insurance company's denial. The employer is the one who sets the rules as to what it will and won't cover. The insurance company is just used to pay the claims for the employer based on the employer's guidelines. If the insurance company denys the claim, you will have to appeal it. Just continue to appeal the claim until it gets to the employer level. If the employer then denys it, it will not be covered.
   — Patty H.

January 12, 2005
who does their claims processing THEY would be the ones to approve you. If you are being sent to the 'city council' then is there an exclusion??? You could talk with the RISK manager to override the exclusion, but if not then yes you would have to go to the city council to override - but what have you got to loose???? all they can say is no, and if its no now you have lost nothing and have everything to gain by asking.
   — star .