Denied - must read this - ThinnerTimes

annie's mom · 06-24-2008, 12:41 PM

Hello everyone,
For those of you that have BC/BS (I am in Maryland - and I realize plans are different) I wanted to share the following:

1) BC/BS will not accept 2 - 3 month plans done at the same time. I was told by Hopkins Bayview they would. For that reason I have ben denied ..so I just hung up with my PCP whereby I scheduled 3 more consecutive visits.

2) Don't trust that your surgeon's office has faxed your paperwork in when they say they have. I just lost 3 weeks due to that.

3) Establish a line of communication with the insurance company. Believe me you will get a lot farther with them.

4)The Diet history IS everything ...I mean everything ...

Thanks for letting me vent ...I think some tears when I get home from work will also help let out my frustration.

never give in ...and never give up.... I won't..

Native2u · 06-24-2008, 01:03 PM

I'm in the same boat....a fighting one.

Sorry that you were denied again....that really stinks!

icvick · 06-24-2008, 05:50 PM

I To Have Bc/bs And Was Denied Several Times The Only Thing That I Did Different Was A 6 Month Dr Supervised Diet. They Would Not Take My Time At Ww As Dr Supervised. I Was Approved The Month I Finished The 6 Month Diet
I Hope That Helps And Gives You Some Hope!!!!

My Surgery Is July 1st I Started My Liquid Diet 3 Days Ago

Good Luck To You!!!!!!!!!!!!

Withacy · 06-25-2008, 03:59 AM

My journey has been over a year so far - and it just last week (I hope) went to the insurance! But because I have Kaiser, and the doctors work directly for the HMO, and they had me follow the HMO's criteria (8 nut visits, 20 therapy sessions, etc), I've been led to believe that there shouldn't be any problem. If there IS a problem, after a year's worth of jumping through their hoops, I'm going to be devistated. Then I'll get angry.

Since I've been with the HMO for nearly 10 years, and I've been Morbidly Obese for the entire time (in their records), that's pretty self evident. And since I've been with the same therapist for the last 5 years or so, and she's been with me through many different diet attempts, she wrote a strongly worded support letter detailing that.

I guess having the same insurance and the same doctor for long periods of time makes the whole process smoother (though not necessarily shorter). And again, since my doctors work for my insurer, my insurer immediately gets all of my vital information whenever I go in to see the doctor. And I just found out I can even access my records online myself. But I haven't found anywhere where I can see if my doctor's recommendation was approved (when it's approved). Bummer.

SueRN · 06-26-2008, 05:25 AM

I got hung up on the 6 month Dr supervised diet with Highmark BC. I had everything else and theother 2 Dr diets I had done didn't count because they hadn't been in the previous 2 years. Doesn't that suck out loud! You are correct when you say the doctor's don't always send everything in or send it when they say they did. I reviewed WLS for BCBSNC and let me tell you about the crap they do send in. Some doctors are awesome with their stuff. Others make me want to go back to law school because their documenation is so bad, I could win law suit after law suit because they would not have a damn thing properly documented and couldn't prove a thing in court. I'd be driving a friggin' Porsche 6 months after I passed the bar they are soooo bad. I know insurance companies have their problems, but we get a lot of the blame for the doctor's mistakes. Remember, we rely on their complete documentation to review against our medical policy. we are not mind readers and do not know what the doctor was thinking or intended to write down. They don't always send in all the needed information. We call to request it but it also needs to be received within a certain time frame. If we don't have all the information by what state and federal laws allow, we have to make a decision based on what we have. So of course it will get denied because we are missing information. In NC, we have 15 days to make a decision, or 3 days if we have all the needed clinical to review. So if you doctor says it takes longer than that in NC, they didn't send it when they said they did and it's easier to blame the insurance company. Do we make mistakes? Of course we do. I am human. I try my best because I always treat my patients and customers like I like to be treated. But I'm not perfect. And mistakes can be corrected as long as the lines of communication are open. Someone suggested to contact the insurance company and I agree. You really need to be informed about what your exact coverage is. 10 people can have the same insurance company and each one can have a totally different benefit package as picked out by their employers. Plus, it's always better to be informed about what coverage you do have whether it be medical, homeowners, or auto insurance. Knowledge is power. Okay....preached enough....my morning Ice tea hadn't kicked in yet. Sue

Withacy · 06-26-2008, 06:30 AM

I worked for private insurance for many years (before coming to CMS - formerly HCFA). People make so many assumptions about their insurance, and more often than they realize they're blaming the wrong people. For instance:

1. Something isn't covered, it's the fault of the evil insurance company. Not so much. If your insurance company doesn't cover WLS, in almost every case it's because your employer didn't buy that policy. I'd bet there are other people who have the same insurance company who do have it covered - because their employer included it in the benefits they're willing to pay for. If it's not covered, and you want it covered, start with your employer.

2. Insurance company denies something they should approve - obviously because they're evil. Like Sue said, it's probably because they didn't get enough information. The part about not being mind readers is SO TRUE! One I kept running into was people would go to the emergency room because they thought (for instance) they were having a heart attack. Turned out to be a cramp or indigestion. So instead of paying a $50 co-pay for emergency care, they're hit with a bill of $200 for non-emergency ER care. How the heck were they supposed to know they weren't having a heart attack?!?!!? (Commense heavy cussing of insurance company now.) Actually, yes the insurance company would consider it an emergency if you THOUGHT you were having a heart attack, even if it didn't turn out to be one - but they have to KNOW you thought you were having a heart attack! And if indigestion is the only thing on the claim form, that's all they can go by!

3. Why can't insurance companies just assume the best? Because you wouldn't believe what some people do! I once had a woman who wanted us (when I was at BCBS of Ohio) to pay for a treadmill, because her doctor told her she needed to get exercise. She actually threatened to sue us over that. She yelled at me (and I didn't even laugh at her).

By all means, CALL YOUR INSURANCE COMPANY - never assume they know everything you think they know. Heck, you wouldn't believe what I see as a fed. People who work for doctors can be (not all, by any means) complete idiots. Or they don't give a crap. And insurers can't base their judgement on what they don't know.

Be nice, make a friend - and you'd be surprised hard someone can work for you.