Confessions of a lurker...

[duh_Mom]

So I have been lurking a bit and trying so very hard not to be discouraged. I am still battling the insurance to pay for my surgery. I am up to 3 denials. I wonder what the record is… I tried to do what is suggested and get the exact verbiage of what is expected – It seemed like everything was in order – the contacts at BC and the insurance person at the docs office all agree they do not know why it is not f’ing approved.


Anyway, after the 3rd denial the doc was going to do a peer to peer – well the insurance person at the docs office and the office manager put their heads together and decided to resubmit with different cpt codes. It seems they left out the cpt code for lapband failure and were requesting only the DS Revision. It has been a week now since that was resubmitted. We will be checking with them again tomorrow. I am pessimistically hopeful. I am mad as hell this has been going on since November with one mistake after another – either at the docs office with the ‘missing’ cpt code, or the insurance company with missing documents and routing to wrong places.


For several weeks, I avoided the boards – I read 2 regularly – well 3 counting the Docs facebook page - I just could not read one more time about people being approved. Gosh, I was / am a angry jealous bitch. I am really angry with this whole process – it should not be this hard to get a life saving surgery approved. Hell, I could be an alcoholic, 5 pack a day smoker on crack cocaine and get approved for a subtotal gastrectomy for ulcers much easier.


So, long whiny post – if the surgery is denied this week then I am going to pay for it myself – by borrowing from my retirement. It just feels like giving up – I have realized that this damn insurance company really triggered my feelings of not doing it right and not being good enough. Hell, I know it is not giving up, it is taking control – I just hate that they are going to win.


I am considering after paying for this myself of getting a lawyer to continue fighting the insurance company to get my money back – anyone ever hear of that? Not sure how much that would cost in legal fees and don’t really want to sue them, and yes, lord help, I just want to have what I am entitled to – and yes I want to win.

 

[Larra]

I hope the new code will do the trick.
If not, have you looked into what rights, if any, you have to external appeal with your insurance and in your state? Depending on how your insurance is funded, you might have such rights. If you don't already have it, get a copy of your EOC (evidence of coverage).
the best person to help in sorting this out is @DianaCox. But you will need the EOC for sure.

And sometimes a peer-to-peer does make the difference, so don't rule that idea out. No guarantees, of course, but nothing to lose by trying.

 

[southernlady]

I hope the new code does the trick as well.

And don't give up...I was on a third appeal for mine...they approved the surgery but NOT my choice of surgeon. And I got mine and THEY paid it.

 

[duh_Mom]

thank you for the feedback - I will get my hands on the EOC - I got the statement about what was required to be eligible for the revision, but I don't think it is the whole EOC. I did read about the appeal process and an external appeal process - I just know it will add so much time an aggravation. I feel like I am missing out on life because I am limited physically at this weight.

Southern Lady - 3 appeals! gosh i would have been crazy after all that. How long a period did those 3 appeals take? Did you handle it yourself or have the doctors office be your liaison?

 

[Munchkin]

You never give up! That's what the insurance company wants you to do. They try to put up enough roadblocks that you will just tuck tail and disappear. I'm hoping you have actually read your policy and not just talked to them?

 

[DianaCox]

Note also that once you have requested preauthorization and have been denied, your right to appeal is vested - if you wish to go forward as a self-pay, while pursuing the appeal for reimbursement, you can do that. Keep in mind that (1) you might not win anyway, and (2) that you must follow the timelines for filing the appeals, which are often rather short (30-60 days), and that they are not stayed just because you are post-op and not feeling up to doing the required filings.

One thing that would concern me about this, however, is that if the denial was based on the WRONG codes being submitted, it might not apply to your situation, because if you were denied for the wrong code, it might not be a valid denial for the procedure you ACTUALLY had. I'd be inclined to wait to get that clarified.

 

[duh_Mom]

Thanks Munchkin, yes i have been reading my policy, talked to HR at work, read on BCBSiL web site, read the denial letters etc.
And Diana thank you! I had not considered that about the wrong codes affecting an appeal if I decide to self pay. That's why I wanted to post here. I know I am too emotionally involved it the whole process to be smart about it.

I did find out today that they have approved the Lap Band removal - waiting on word for the DS - it was expected today, but did not come through - likely due to time zone differences.

 

[jim1969]

I know the feeling! Keep plugging away!

 

[brooklyngirl]

Please don't see it as giving up, I see it as taking charge! Hell, you'd borrow money to pay for a car, why not for your long term health and happiness!

 

[duh_Mom]

Hey you guys, I finally have some type of an answer - have talked to them everyday this week- but did not get and answer until today - BCBSIL has agreed to pay for the lapband removal but nothing else. Said I cannot prove i have been compliant with the lapband protocol. I sent 6 months of dr visits with weights, fills, and notes. Sent note from psychologist for bi monthly visit working on weight / food issues since 2011 - including working with Nuts, and exercise people. Sent note that docs office does not keep track of attendance at 'support' group. Not sure what the hell else I need.

So, I flippin' scheduled surgery - the soonest I could get was 6/16 - I am going to continue to brow beat BCBSIL - @DianaCox , may reach out for an opinion or 2 - not for a week or so - you have enough insanity going on. - Anyway I requested my EOC from BCBSIL - the a HOLEs sent me a letter saying I have coverage. WTF- so, contacted them again and asked for the EOC contractual language that I am covered under. My employer is self insured through them - am I asking the wrong place for the EOC - should i be going to my HR department. Is there another name besides EOC - or are they just being difficult?

 

[DianaCox]

Yes, you have to get the EoC from your employer. The self-funded thing is possibly the biggest problem though - self-funded plans don't have a route of appeal to the state, as they are controlled by the far more lax federal laws, which give companies very low minimum coverage standards to comply with the law.

 

[Will2014]

Hey you guys, I finally have some type of an answer - have talked to them everyday this week- but did not get and answer until today - BCBSIL has agreed to pay for the lapband removal but nothing else. Said I cannot prove i have been compliant with the lapband protocol. I sent 6 months of dr visits with weights, fills, and notes. Sent note from psychologist for bi monthly visit working on weight / food issues since 2011 - including working with Nuts, and exercise people. Sent note that docs office does not keep track of attendance at 'support' group. Not sure what the hell else I need.

So, I flippin' scheduled surgery - the soonest I could get was 6/16 - I am going to continue to brow beat BCBSIL - @DianaCox , may reach out for an opinion or 2 - not for a week or so - you have enough insanity going on. - Anyway I requested my EOC from BCBSIL - the a HOLEs sent me a letter saying I have coverage. WTF- so, contacted them again and asked for the EOC contractual language that I am covered under. My employer is self insured through them - am I asking the wrong place for the EOC - should i be going to my HR department. Is there another name besides EOC - or are they just being difficult?

I can't even begin to tell you what criminals those thieving bastard insurance companies are. They have 2 books of policies, one is on the books and public, the other is off the books and very definitely private. This one contains policies such as the one where certain procedures are automatically denied on the 1st request, patients are coerced into obtaining procedures less efficacious than they should be receiving, or the procedure is agreed to....but there is no way to actually make this a reality. Such is what happened in my case. I worked for a large hospital chain and as I weighed 412 lbs, was easily a candidate for the DS procedure. They willingly agreed to do it...but I must use a doctor in my hospital chains organization. So it was approved...but there was no actual way I could have it done because no Dr. would do it. NICE!! So I had to go to Mexico to have it done by the late great Dr. Alberto Aceves and I paid out of pocket. I HIGHLY recommend you consider Mexico if you are not approved as the cost is MUCH lower and the skill level of Dr. Ungsons team is beyond reproach. I would ONLY recommend Dr. Ungson and his team in Mexicali, Mx though! There are many poor hacks there who are reportedly misrepresenting surgeries as DS, but are not. Dr. Ungson trained my doctor and many others following Dr. Hess's model. He is a great man. My cost was $12,500 total and I was picked up at the San Diego Airport, brought to the hospital for a 7 day stay, and returned to the airport to go home. It's all red carpet treatment, and the hospital care was the greatest I've ever witnessed. You have options my friend! But I hope you win your appeals and can have it close to home.

 

[DianaCox]

But, here's the thing - you said: "Said I cannot prove i have been compliant with the lapband protocol."

That might be a little crack - that sounds like they WOULD cover the revision, if you HAD been compliant - but then they gave you an impossible standard to meet - PROVING you had not been non-compliant.

I would turn that right back around at them - tell them you have said you were compliant, your doctor's records show compliance, and THEY cannot prove you WERE not compliant. The burden is on THEM to prove non-compliance.

You might be able to get them on this, but it MIGHT cost you more in legal fees than it would cost to pay for your doctor to perform the DS during the same procedure in which he removes your crapband.

You could pursue the appeal, and if the insurance company says no, ask your company if they would review the case themselves - because in a self-funded plan, the company pays the medical bills in the end, not the insurance company - they are only administering the plan.

 

[duh_Mom]

@Will2014 - couldn't agree more about insurance companies - I did investigate Ungsons team for surgery - mainly due to cost. Wouldn't even need to pay for plane ticket - could go on points, but being that far from home for surgery and follow up scares me - the wife wasn't happy about it either. so going to borrow from my retirement - if I don't have this surgery, there is not going to be a retirement - so damn.

@DianaCox - I agree - I too was left with the opinion that had I been "compliant" they would pay the revision and will do as you suggest - still trying to get the EOC - has been a run around - called my HR line and was told to go to the website - I told them all that is on the website is the summary - i need the document that the summary is based on. was told 2 things - they don't have it... then she kept talking ...and was told they can't give it to me. wtf...
so, have reached out to the director of HR at our national office - who reached out to someone at another corporate office... shit.

Perhaps this will be the same person I can appeal to at the company as well.

 

[southernlady]

I agree - I too was left with the opinion that had I been "compliant" they would pay the revision and will do as you suggest - still trying to get the EOC - has been a run around - called my HR line and was told to go to the website - I told them all that is on the website is the summary - i need the document that the summary is based on. was told 2 things - they don't have it... then she kept talking ...and was told they can't give it to me. wtf...
so, have reached out to the director of HR at our national office - who reached out to someone at another corporate office... shit.

Perhaps this will be the same person I can appeal to at the company as well.

Remind them YOU have a legal right to a copy of your exact policy FOR YOU...and it can either come from them or from the insurance company but you want it.