jimlaman8

Insurance is saying bariatric surgery not covered after 6 months of prep classes and a surgery date.. Lindstrom Obesity Advocacy?

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We have a situation, where my wife has gone through bariatric surgery prep work.. was told by the physicians office that she should be covered if she met criteria for the surgery.. even now had a scheduled surgery date.. only to find out now that the insurance wont pay for the surgery, because bariatric surgery is not covered under any circumstance.. its an unreal situation after months of classes/pscyh evals copays and visits to find this out.

I dont think this was the reason, but my employer changed ppo levels to a lower deductible / higher premium which changed insurance policies as of 11/1/2016.. much of the prep work and meetings began around oct time frame.

The insurance (UPMC) certainly did not degrade in coverages.  

Whats strange is that the office wont call in the appeal themselves.. she had to now call the medical card number and verbally state the appeal.. they claim they dug into phone records (only phone calls) and said no one ever said it would be covered (dr office phone records), however the in person visits told a different story.

At this point it feels hopeless and out of reach.. i'm not sure if a place like this advocacy lawyer could even help.. i've read it costs around $600, but if they win i suppose a small price to pay.

 

Any thoughts/experiences?

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My daughter was the insurance expert in the bariatric program at Mass General Hospital for a few years. Its was her job to get people approved, both for their benefit as well as the hospital. Mass General is a 1A certified bariatric center off excellence, and even though I had my surgery at a different stoop rated Boston hospital, their program also had an insurance expert and hat person was the first one to speak during indoctrination.

Check further, you may well have resources that don't involve legal action, and good luck!

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To echo what Tom wrote, I suggest that ASAP you reach out to your surgeon's weight loss surgery office to see if the person there who handles the office's insurance claims can help you.

I am an attorney who practices (among other things) insurance coverage law. It is very possible that when your health insurance changed that some coverages were dropped - including perhaps coverage for weight loss surgery.  Usually such dropped coverages are not mentioned since so few people use them.  

I am skeptical that any $600 service will be able to help you.  If the surgeon's office cannot help, you still may get coverage if you keep calling the insurance company, appeal within the company, and (if necessary) complain in writing to your state's insurance department or attorney general's office.

Be sure to be very active on this now, as the upcoming repeal of Obamacare (or the ACA) in the next few days/weeks/months almost certainly will result in less coverage for many health conditions in the future.

Finally, if both of you work for different employers then you should see if you can get health insurance that covers weight loss surgery from the other employer. 

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I have a similar issue as Jimlaman8 only I am not married and it is my surgery.  I have gone through all of the test, classes and had a surgery date.  I was going to have my pre op tomorrow and they called today to say it was denied.  I called my insurance and they said that it is excluded.  They told me to have the doctor call to appeal and state the medical reason why it needs to be done.  I called and left a message with the person who handles the insurance.  They didn't check ahead of time before I spent the $4000 for my deductible to get everything done.  I have summers off because I work at a school and this was going to allow me to heal before I go back to work.  Now if it gets approved on an appeal I may not be ready when school starts back depending on how long the appeal takes if the doctor will even take care of it like the insurance said they are supposed to.

 

Frustrated!!

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8 minutes ago, LoriC said:

I have a similar issue as Jimlaman8 only I am not married and it is my surgery.  I have gone through all of the test, classes and had a surgery date.  I was going to have my pre op tomorrow and they called today to say it was denied.  I called my insurance and they said that it is excluded.  They told me to have the doctor call to appeal and state the medical reason why it needs to be done.  I called and left a message with the person who handles the insurance.  They didn't check ahead of time before I spent the $4000 for my deductible to get everything done.  I have summers off because I work at a school and this was going to allow me to heal before I go back to work.  Now if it gets approved on an appeal I may not be ready when school starts back depending on how long the appeal takes if the doctor will even take care of it like the insurance said they are supposed to.

 

Frustrated!!

Hi Lori, you can affect the result. Let me strongly echo what Res Ipsa and tmcgee have said.

Yes, in my view your surgical team should have checked your eligibility before you went down the path. They definitely have at least a moral obligation to help you navigate this, and you can argue that as the knowledge experts they should have recognized if you were not eligible. Your intake interview should have included your background data and they should have crossed it against your insurance. At the next meeting they could have told you why you qualify or not, and what barriers or obstacles existed. You could have then stopped your engagement with them before you got thousands of dollars into this, or if you needed to do something else - like try a diet program monitored by a medical professional - you could have either provided evidence of a past attempt, or gone through that drill. 

I would speak directly to the person who handles the insurance for your surgical team and get him or her on board with you. My experience is that getting that person angry at you will not help, so if your temper could be an issue... take a nice pill and just be factual. What you want is the insurance contact person to essentially tell you, and the surgeon, what the reason for the denial is so it can be fought most effectively. Find out what your appeal mechanisms are. The insurance company will have an identified mechanism. Escalate to the level of your state attorney general and the state insurance commission. 

(1) Get a list of "accepted" reasons for the surgery. Then cross your own medical history against the "accepted" reasons. If you fit -> then they pretty much have to approve it. 

(2) If you don't fit, you'll know why. If your insurance company has stupid or ridiculous reasons for excluding the surgery, identify them and then appeal stating that the standard of effective care is surgery. By this I mean, for example, that you have to be on 4 anti-hypertensive drugs and not 3, then that is clearly a stupid reason. The point is you have hypertension. You can tell them that they will be asked, to prove in a court, that people on 3 drugs for hypertension are just fine and don't need surgery, whereas people on 4 drugs are ok to have it. You will win before a jury in a nanosecond and they will be held up to the ridicule they deserve.

If bariatric surgery is excluded from your medical plan, appeal it and outline how it will add years to your life and decrease medical care costs. 

The squeaky wheel gets the approval. Insurance companies sometimes hope that through your frustration you will give up. Do not give up. Be strong, advocate for yourself, and be persistent. 

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On 1/31/2017 at 3:59 PM, jimlaman8 said:

We have a situation, where my wife has gone through bariatric surgery prep work.. was told by the physicians office that she should be covered if she met criteria for the surgery.. even now had a scheduled surgery date.. only to find out now that the insurance wont pay for the surgery, because bariatric surgery is not covered under any circumstance.. its an unreal situation after months of classes/pscyh evals copays and visits to find this out.

I dont think this was the reason, but my employer changed ppo levels to a lower deductible / higher premium which changed insurance policies as of 11/1/2016.. much of the prep work and meetings began around oct time frame.

The insurance (UPMC) certainly did not degrade in coverages.  

Whats strange is that the office wont call in the appeal themselves.. she had to now call the medical card number and verbally state the appeal.. they claim they dug into phone records (only phone calls) and said no one ever said it would be covered (dr office phone records), however the in person visits told a different story.

At this point it feels hopeless and out of reach.. i'm not sure if a place like this advocacy lawyer could even help.. i've read it costs around $600, but if they win i suppose a small price to pay.

 

Any thoughts/experiences?

Strongly urge that you appeal the denial. Insurance companies often hope you will not be persistent. People with cancers get the insurance companies to cover the new drugs that cost hundreds of thousands of dollars fairly frequently. You may have a good outcome by cooly, calmly outlining why your wife should have this approved. Bariatric surgery is much less expensive than the expense of the complications of obesity; and it is the only documented effective treatment for obesity and its complications. You may not get anywhere telling them they should cover bariatric surgery for everyone, but you may get someplace by arguing your wife given her circumstances should have this approved. Please see some of the text written in response to Lori. 

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