Hello everyone!
I'm new to this forum and was looking for any help or advice. Here's my story...
I have an Aetna HMO through my employer that limits me to a cetain local hospital & their providers only. If I go to our other local hospital or one of their providers then my claims would be rejected for out of network. Anyways, I began my bariatric journey at the beginning of this year with the hospital that I'm limited to. The insurance coordinator for the weigh loss program called Aetna to verify if the services would be covered or not. Aetna informed them that bariatric services would not be covered for me because I did not meet one of their bariatric requirements and that was that I wasn't Type 2 diabetic. My employer plan through Aetna would only pay for bariatric services only if the insurer is Type 2 Diabetic not pre-diabetic. Aetna told the ins coordinator that my classes & surgery would be denied by them. Luckily I have great secondary insurance that does cover all bariatric service so we went ahead and scheduled all of my classes & tests.
I was scheduled for surgery on 8/28 and everything was going great until yesterday when I received a call from the weight management program advising me that Aetna was denying my preauthorization because my hospital was not one of their approved IOQ/Center of Excellence facilities. They completely left out that I was being denied because I was not Type 2 diabetic which was what they informed my hospital months ago before I started this journey.
After some back and forth Aetna revealed that my employer had just updated the bariatric services clause in our insurance on 8/1/23 to remove the Type 2 Diabetic requirement so now I would be eligible for 100% coverage through Aetna which is great but now they're saying that I need to go to one of their IOQ facilities after going through 6 months of the program with my hospital.
My issue is is that Aetna HMO limits me to my hospital and their IOQ facilities would be considered out of network for me. They then told me that because of this my bariatric surgery at one of their IOQs would also be rejected!!!!
I spoke to my surgeon's benefit coordinator and she advised me that because my employer & Aetna both changed the bariatric services clause in my insurance and they are now saying I'm covered 100% but that services & surgery need to be done at an IOQ facility, she can no longer submit for preauthorization through my secondary insurance even though my secondary has been paying for all of these services for the past 6 months. She said that if they would've rejected my preauth for the Type 2 Diabetes clause that was in place when I started the program then she would've been able to submit the preauth to my secondary because Aetna was essentially saying that I did not have bariatric coverage based of me not being diabetic.
So now my surgery is cancelled.
Aetna is saying that I have 100% bariatric coverage but I can't use my hospital because they are not one of their IOQ facilities but Aetna limits me to only using this specific hospital as it's in network with them.
Aetna is also saying that if I do go through one of their IOQs then I would be rejected because all of their IOQs are out of network for me.
My hospital is telling me that because Aetna is denying my preauth only because they're not an IOQ, that their hands are tied now and they can't submit preauth to my secondary because Aetna is technically saying I have 100% bariatric coverage through them and in order for them to pay I would have to use one of their IOQs even though Aetna has already made it clear that they will not cover my surgery at an IOQ because they'd be out of network.
I'm extremely upset & frustrated by all of this and have cried for hours trying to make sense of all of this. I have a primary insurance (Aetna HM0) that now covers bariatric services 100% to non-diabetics & pre-diabetics but will not cover the services for me now because my dictated hospital is not one of their IOQs and their IOQs are out of network. I have a wonderful secondary ins that will & has been covering my bariatric services but now my hospital cannot submit to them because of Aetna. So I basically have 2 insurance that provide 100% bariatric coverage but I can't utilize any of them to cover my surgery because of Aetna.
Has anyone ever heard of such craziness or experienced anything similar? Does anyone have any advice for me? Any suggestions are welcome. I just want to finally get this surgery and get my health on track.
