Denied on May 9th - Page 3 - ThinnerTimes

SueRN · 05-22-2008, 08:55 AM

Most insurance companies require a documented, this means offical weights taken by a healthcare office that were recorded, 5 year weight history. Having reviewed gastric bypass surgery for BCBSNC, I can tell you that the doctor's offices do NOT always send in all the information we need to review these cases. We, by state and federal laws, have a specified time frame to determine an outcome. If we don't have what we need, and the MD office doesn't get it to us, we have to deny the request. Sometimes, we can get the MD office to cancel the request so they can send everything in at once if they need more time. That way, we don't have the denial on file and have to deal the the appeal crap. You'd be surprised at the requests we get to review where the person's BMI's have only met criteria for the past year or so. They can't lose the weight they had from having a baby and rush to get gastric bypass. The surgeon doesn't have the balls to say this is inappropriate so they let the insurance company be the bad guy. I did approve a case once for a man who sent me a photo album with date stamped pictures which showed he was obviously morbidly obese. He was 500+ lbs. He met all the other criteria and I approved him and even called him to thank him for the creativity! You have to remember that the insurance company only can review the documentation it is given. We don't see the patient or can read the mind of the MD if it is not documented. And half the time, what is documented is crap. Having fought my own battle with Highmark BC for a year, I really feel where you are coming from. Make sure that all the documentation was sent in for review. If the past 5 year weight history is holding you up, do you have any older weights that show morbid obesity? We have used those to approve cases. If they were 300 lbs in 1997, and 300+lbs in 2006 and 2007, we can safely say they were probably 300+ lbs in the missing years we need to review. Like everyone else said, don't give up. This is all about a long term process with you and the changes you need to make and actually the surgery becomes a very small part in that in the long run. Keep plugging away and it will happen. Let me know if there are any iinsurance specific questions or problems I can help you with. Good luck, Sue

Godsblessedme · 05-22-2008, 09:15 AM

i was waitin for our review nurse Sue to come reply

SueRN · 05-22-2008, 12:10 PM

Sorry I took so long to respond. My cousin's husband committed suicide a few weeks ago. Then my Grandmother fell ill and I ran up to NJ to see her. Just got back last week and she passed away last Wed so I had to turn around and head back to NJ. Just got back home yesterday. Haven't had much time to get on line and I feel so out of touch with what's been going on at TT!!!! Sue

Native2u · 05-22-2008, 01:41 PM

Quote:

Originally Posted by doxielover

I'm so sorry about this happening to you. Were you denied after you had been through all of your consults or denied from being referred to the surgeon at all?

I was denied after all of my consults and 6 month diet w/my doctor was done. I have everything completed.

I called my WLD's office today. I have heard from them yet. I'll keep everyone posted.

Cross your fingers that my insurance company will actually read the paperwork that was submitted this time. I know that my doctors office is going to "highlight" and "flag" the very important parts. Basically, HELLO....READ THIS!!!!

Native2u · 05-22-2008, 01:50 PM

Quote:

Originally Posted by SueRN

Most insurance companies require a documented, this means offical weights taken by a healthcare office that were recorded, 5 year weight history. Having reviewed gastric bypass surgery for BCBSNC, I can tell you that the doctor's offices do NOT always send in all the information we need to review these cases. We, by state and federal laws, have a specified time frame to determine an outcome. If we don't have what we need, and the MD office doesn't get it to us, we have to deny the request. Sometimes, we can get the MD office to cancel the request so they can send everything in at once if they need more time. That way, we don't have the denial on file and have to deal the the appeal crap. You'd be surprised at the requests we get to review where the person's BMI's have only met criteria for the past year or so. They can't lose the weight they had from having a baby and rush to get gastric bypass. The surgeon doesn't have the balls to say this is inappropriate so they let the insurance company be the bad guy. I did approve a case once for a man who sent me a photo album with date stamped pictures which showed he was obviously morbidly obese. He was 500+ lbs. He met all the other criteria and I approved him and even called him to thank him for the creativity! You have to remember that the insurance company only can review the documentation it is given. We don't see the patient or can read the mind of the MD if it is not documented. And half the time, what is documented is crap. Having fought my own battle with Highmark BC for a year, I really feel where you are coming from. Make sure that all the documentation was sent in for review. If the past 5 year weight history is holding you up, do you have any older weights that show morbid obesity? We have used those to approve cases. If they were 300 lbs in 1997, and 300+lbs in 2006 and 2007, we can safely say they were probably 300+ lbs in the missing years we need to review. Like everyone else said, don't give up. This is all about a long term process with you and the changes you need to make and actually the surgery becomes a very small part in that in the long run. Keep plugging away and it will happen. Let me know if there are any iinsurance specific questions or problems I can help you with. Good luck, Sue

Thanks for responding and putting it the way you did......straight up. I have refused for anyone to take pictures of my for years. Although, I have some pictures of myself. There is one problem......at first my doctor was totally in shock at the fact I was thinking about the surgery, due to the fact that I really carry my weight really well. I had to tell him.....LOOK at my weight! for him to say...OMG, you don't look that heavy.

I have a call into my doctors office now, they say that they'll call me back within 24 hours......we'll see. I'm going to see my PCP on Tuesday, next week. Is there anything more that he can do to help me, at this point???

Godsblessedme · 05-22-2008, 07:18 PM

Sue wow im so sorry for your loss's

SueRN · 05-23-2008, 06:24 AM

Do you have weights from another MD....like a GYN? I only go to my GYN regularly so I used those weights to submit.I had a 10 year weight hx. I had done 3 MD sponsored diets in my life, but because they hadn't been done in the previous 2 years when the request was submitted, my gastric bypass had been denied. My PCP even did a peer to peer with the MD at Highmark BC. We appealed but still lost. But while all that crap was going on, I was meeting monthy with my PCP and he was documenting my 6 month diet attempt. Then I finally got it approved. As far as letting people take pictures of me, I'm with you. I was the one taking the pictures and hated to see me in any of them at that time. Not going to a Md regularly is bad enough, but we have people that do go to their MDs al lthe time and REFUSE to be weighed. We get the office note, but there is no weight and it's documented that the patient refused. Now, they have no record. I actually had one MD write a letter saying that the patient had worked for him in the past and he estimated her weight to be such and such, without having actually weighed her. I'm not suggesting fraud, but there are all ways I have seen people try to create a weight history. Some make up letter head from a doctor's office, some try to add it to an exisiting prescription that they are going to get filled (we don't fall for that one). Have you had any urgent care or ER visits where a weight may have been recorded?

Native2u · 05-23-2008, 12:00 PM

Quote:

Originally Posted by SueRN

Do you have weights from another MD....like a GYN? I only go to my GYN regularly so I used those weights to submit.I had a 10 year weight hx. I had done 3 MD sponsored diets in my life, but because they hadn't been done in the previous 2 years when the request was submitted, my gastric bypass had been denied. My PCP even did a peer to peer with the MD at Highmark BC. We appealed but still lost. But while all that crap was going on, I was meeting monthy with my PCP and he was documenting my 6 month diet attempt. Then I finally got it approved. As far as letting people take pictures of me, I'm with you. I was the one taking the pictures and hated to see me in any of them at that time. Not going to a Md regularly is bad enough, but we have people that do go to their MDs al lthe time and REFUSE to be weighed. We get the office note, but there is no weight and it's documented that the patient refused. Now, they have no record. I actually had one MD write a letter saying that the patient had worked for him in the past and he estimated her weight to be such and such, without having actually weighed her. I'm not suggesting fraud, but there are all ways I have seen people try to create a weight history. Some make up letter head from a doctor's office, some try to add it to an exisiting prescription that they are going to get filled (we don't fall for that one). Have you had any urgent care or ER visits where a weight may have been recorded?

Sue, thanks for the ideas.

I actually lost my health care insurance in December 2005 and got insurance back August 2007. I didn't see any Doctor, due to the fact, I couldn't afford it. I even signed up for Medicaid and they turned me down.....reason why??...my boyfriend was living with me. I thought it was crazy, cause I was a single Mom with 2 kids under the age of 18 yrs old...living with me. I told the Medicaid person that my boyfriend paid all of our bills.....they didn't care. That's the wonderful State of Florida for ya. I did however go to the ER during the time that I had NO insurance, I will have to check and see if they have a weight on file for me. Do you know how I would get those records? I'm wondering if I can just call them and ask for the paperwork during that visit. My visit wasn't weight related, but, they might have a weight for me.

I also have paperwork with weights for me, during the time that I didn't have insurance.....I was going to a weight loss clinic in my area. I only think that I visited 4-5 times...that was all that I could afford and it wasn't working either. I know that I can get those records, if you think that will help my case.

SueRN · 05-27-2008, 05:38 AM

For the ER record, they will need a signed release to get you a copy of any report. Call that hospital and ask for medical records. they can advise you on how to get a copy. Ask the weight loss center to Write a letter on their letter head outlining your visit dates and weights recorded along with a copy of the actual document where they recorded your weights. Include this with a letter from you explaining just what you explained to me. Again, some people are real sticklers for the medical policy. Others, like me, try to cut thru the crap and only care if the weight history look legit. Believe me, I have seen some major fraudulent weight documentation. If you have older weights, make sure you get those too. Just another piece of advice...make sure they don't use a hi-liter on the actual stuff we need to read and then fax it. All the important information comes out black and we can't even read it. Although a good reviewer doesn't need it, a small check or star would be better if they just have to do it. It also helps if they just send what the insurance company needs to review. I have some surgeons that send 40-60 pages of crap when I really only need to see about 10. Keep us posted on your progress. Sue

Native2u · 05-27-2008, 06:51 AM

Thanks a bunch Sue. I'll do just that. I will call the hospital and get the records. I will also call the weight loss center and get them to write a letter (on their letterhead) and I will also write another letter to the insurance company explaining why I didn't see a doctor during my "no insurance" time.

Thanks again!