Problems with my insurance

[Webmommy]

I tried to get an appointment with a weightloss surgeon in Denton (Dr. Ayoola) and they checked my insurance and got back to me. I have primary insurance through a self-funded plan with my husband's employer and Medicare secondary.

Problem 1: They said my primary has a bariatric surgery exclusion. I too checked my insurance and they said no the first time too. I said they were mistaken because my employee benefits manual says that it does. You do have to have diabetes as a comorbidity. I told this all to the insurance coordinator too. I have no comorbidities but my bmi is 44.

2) She told me if my primary won't pay then my secondary won't cover it either. What? Why?

3) Why does my primary have so much control over my Medicare benefits?

What do I do? If the surgeon's office isn't getting the right information from my insurance how can I remedy that? Get a copy of my manual or the evidence of coverage? But what if my insurance still tells them it isn't covered when they give the codes? How can I compete with that?

How do I find these rules that talk about primary insurance and secondary Medicare and how coverage and denial works?

How screwed am I?

 

[southernlady]

I tried to get an appointment with a weightloss surgeon in Denton (Dr. Ayoola) and they checked my insurance and got back to me. I have primary insurance through a self-funded plan with my husband's employer and Medicare secondary.

Problem 1: They said my primary has a bariatric surgery exclusion. I too checked my insurance and they said no the first time too. I said they were mistaken because my employee benefits manual says that it does. You do have to have diabetes as a comorbidity. I told this all to the insurance coordinator too. I have no comorbidities but my bmi is 44.

2) She told me if my primary won't pay then my secondary won't cover it either. What? Why?

3) Why does my primary have so much control over my Medicare benefits?

What do I do? If the surgeon's office isn't getting the right information from my insurance how can I remedy that? Get a copy of my manual or the evidence of coverage? But what if my insurance still tells them it isn't covered when they give the codes? How can I compete with that?

How do I find these rules that talk about primary insurance and secondary Medicare and how coverage and denial works?

How screwed am I?

When I had my DS, I had United Health Care as my primary and Medicare (an Advantage plan) as my secondary. UHC denied me because I had not been over a 35 BMI for at least five years. (I would drop 5 lbs and be a 34.8 which is "TOO LOW").

I had surgery, and of course, UHC denied the charges (they had to submit to my primary first) and then submitted to Medicare who paid the bill.

https://www.medicare.gov/Pubs/pdf/02179.pdf It's called Coordination of Benefits. And the insurance coordinator needs to re-read that. That pdf also gives you a number to call.

 

[Webmommy]

That doesn't seem like it's a good sign if I have to tell them how to do their job.

 

[DianaCox]

That doesn't seem like it's a good sign if I have to tell them how to do their job.

Welcome to the real world of insurance fraud - by the insurance companies. Most people don't even know that they can question what they are told, which is all-too-often false, and of course in favor of the insurance company not paying.

 

[Webmommy]

Welcome to the real world of insurance fraud - by the insurance companies. Most people don't even know that they can question what they are told, which is all-too-often false, and of course in favor of the insurance company not paying.

This company screwed me sideways before saying they'll cover two back procedures and then reneged after I had both. I was stuck with a $5k bill and it was major FUBAR. I had a teensy weensy breakdown over that. This company is the devil.

So @DianaCox how do I prove to the insurance coordinator at the surgeon's office that my primary does cover it and that Medicare will also cover it even if my primary doesn't? Especially when she calls with codes and then they tell her no? Do self-funded insurance plans have that much leeway they can make up crap as they go along? She was trying to get me to go self-pay which I found shady.

 

[Webmommy]

This is rhetorical but how come she doesn't know that Medicare WILL pay? Isn't that her job to know these things?

 

[DianaCox]

Call the number that Liz suggested for Medicare. Since it is likely that they would be the ones paying for it, you should ask them, as well as a written evidence (citation to the portion of the Medicare rule) that they would pay for it if your primary denies.

 

[southernlady]

This is rhetorical but how come she doesn't know that Medicare WILL pay? Isn't that her job to know these things?

She doesn't.

However, Medicare will pay if all the t's are crossed and i's are dotted. But Medicare does not pre-approve any procedure. You have to hope and pray they will.

 

[Webmommy]

I called the number but they said I needed to call the regular Medicare number. So I did and the next agent gave me the information and when I asked how I could get a copy of what he read to me, he said that was just their information for the agents. I'm going to see if I can find that tonight on their website and if I can't I'll call again tomorrow.

The insurance coordinator for the surgeon said specifically since Aetna won't pay as primary then Medicare would not pay either. That is not true according to Medicare. Shouldn't she know this already? Why is she telling me misinformation? According to the Medicare agent if my primary doesn't pay and the provider submits it to Medicare first then Medicare will deny the claim. So they need to submit the charges to my primary, let primary decline and then submit it to Medicare. Bariatric surgery would be covered by Medicare if I met certain conditions which is incidentally the same as Aetna.

I'm going to call Aetna tomorrow and get an evidence of coverage for bariatric surgery because our benefits manual says it's covered. It seems like it is better (in my mind) I don't meet Aetna's criteria for bariatric surgery than just accept that there's an exclusion for bariatric surgery. I'm stubborn that way and have something to prove. I'm hoping if I bring both Aetna's evidence of coverage on paper as well as Medicare's rule that she'll stop saying that Aetna won't pay, Medicare won't pay so you gotta selfpay! Between Aetna lying, her misinformation about Medicare and pushing self-pay it feels shady. I'm tempted to go elsewhere because I forewarned her that Aetna tried to say they didn't cover it. But there really isn't anywhere elsewhere that's feasible for my family.

I asked her what should I do if they keep telling her bariatric surgery isn't covered when I know it's covered. Like how can I compete with that? She just repeated herself that Aetna doesn't cover it so Medicare won't "but we have self-pay options available." She said I could have them call her too. I do have a Nurse Case Manager, maybe she can help. Sorry, I'm ranting. I'm just so frustrated by incompetence and lies.

Am I the right track? Can I make a complaint about Aetna?

 

[Larra]

I understand your frustration, but digging in your heels and/or accusing someone of being shady when in reality they are probably just ignorant or your situation will get you nowhere.
@southernlady has given you a roadmap. Get whatever you can in writing of course, but get a consult with Dr. Ayoola, have his staff submit to Aetna (when you have met the requirements), get your denial from them and then have them submit to Medicare. If they have never dealt with this before, maybe they will learn something that will help other patients in the future.

Document everything - make a note of every phone contact with your insurer or HR with name, job title, phone number, date, time, and summary of conversation. If you run into a roadblock, request to speak with a supervisor and get that person's name, etc.

The bottom line is that 1) you know what you want, and 2) Dr. Ayoola has an excellent reputation as a DS surgeon, and his expertise is far more important than the expertise of his office staff. Keep you eyes on the prize.

 

[Webmommy]

Well, as much as I may feel like it I have not and will not accuse Aetna nor the surgeon's staff of anything. My son is in special education and negotiating/finagling with his school for the education in which he's legally entitled is awfully similar to this insurance struggle. I can't effectively advocate for him if I ostracize the people at school. Worse, they may retaliate.

Sometimes their motives have been suspect and sometimes they just give out bad information because they've been given wrong information. I've learned to keep my ranty mouth shut with them, speak up when necessary ... and then vent when I'm away from them! But I do know I need to be stubborn and dig my heels in enough to not give up. Yesterday, I was ready to give up.

Thanks for the info though y'all. You don't know me so all you can go by so far is that I'm a raving lunatic! I am but I can keep it under wraps! Rest assured, I am doing what you've said to do.

 

[Webmommy]

Holy cow I'm confused and frustrated now after I made calls to surgeon's office, Aetna, and Medicare. Coordination of Benefits and Recovery said they can only answer which insurance is primary or secondary. They referred me to a claims specialist which confirmed that Medicare will not pay as primary and may only pay at 20% if my primary denies it. On Wednesday, the agent at Medicare said that Medicare would pay as primary if primary denied claim. The claims specialist and the surgeon's insurance billing person both agree that if I didn't have a primary, Medicare would cover at 80%.

Also, here's more confusing facts. Aetna does NOT cover bariatric surgery. However, Walmart offers the supplemental benefit through a third party administrator called Health Design Plus which incidentally only covers gastric bypass and sleeve through their centers of excellence. Aetna still processes the claims though and coordinates with Health Design Plus. I think it's important to note that Aetna/Walmart is also doing their campaign of misinformation to health providers when looking to check into coverage for ABA- Applied Behavior Therapy for my son.

I spoke to two people at the surgeon's office, one who does insurance verification and the other who does insurance billing. She asked me if I had any obesity comorbidities and I said I wasn't sure what they all were. Then she said she didn't know why I was "arguing" with her about comorbidities and I said I didn't understand why she thought I was arguing and what are all the comorbidities that are considered obesity related? It was really odd because in the last call she said I was arguing with her too when I was just asking her questions. It was like I was a kid getting in trouble for talking back by speaking at all.

She even got irritated when I asked what I could do to help her get the same information that my insurance was telling me like a copy of the employee manual and doing a conference call with my nurse care manager. She was peeved at my offer of help. The more questions I asked the more agitated and threatened she became and it was odd. She abruptly transfered me to the billing person and he was more open to the possibility of conference call and I told him too about the supplemental coverage. They're going to recheck and I will talk to my nurse care manager and let her handle it just like I'm going to for my son's ABA therapy too.

Whew, I need a nap! If it was only one thing in our lives that was this complicated it would be okay but it's this complicated for most major issues in our lives. In the meantime, I'm going to get my physical and do a sleep study because I do not know for certain if I do or don't have co-morbidities. I mistakenly thought that was part of the process and that my bmi was high enough not to need a comorbidity. Anyway, that's where everything is at the moment and I have accrued documentation as well.

 

[southernlady]

Holy cow I'm confused and frustrated now after I made calls to surgeon's office, Aetna, and Medicare. Coordination of Benefits and Recovery said they can only answer which insurance is primary or secondary. They referred me to a claims specialist which confirmed that Medicare will not pay as primary and may only pay at 20% if my primary denies it. On Wednesday, the agent at Medicare said that Medicare would pay as primary if primary denied claim. The claims specialist and the surgeon's insurance billing person both agree that if I didn't have a primary, Medicare would cover at 80%.

If UHC had paid for my DS, then yes, Medicare pays 80% of what UHC would not have paid.

BUT because UHC denied my claim as primary, Medicare would have paid 80% with me responsible for the remaining 20%. However, I had a Medicare Advantage plan as my secondary, not straight Medicare. My Medicare Advantage paid 100% of reasonable and customary charges after my initial deductible of about $350 (2011).

Are you on regular Medicare or an Advantage plan as secondary? Maybe during open enrollment this fall, get an Advantage PPO plan as secondary and try in Jan.

 

[southernlady]

The biggest issues with Medicare is they do not pre-cert a damned thing so no "guarantee" of payment. Which is why if you are on Medicare, surgeons, doctors, hospitals, etc all have Medicare patients sign a responsibility of payment if Medicare doesn't pay.

They pay "reasonable and customary" which is no where even close to what surgeons and hospitals even get paid with a self pay patient.
Example, my surgeon billed $15k for his surgery fee. Hospital billed $45k. Surgeon was paid less than $3,000. Hospital got $8,000.

 

[Webmommy]

If UHC had paid for my DS, then yes, Medicare pays 80% of what UHC would not have paid.

BUT because UHC denied my claim as primary, Medicare would have paid 80% with me responsible for the remaining 20%. However, I had a Medicare Advantage plan as my secondary, not straight Medicare. My Medicare Advantage paid 100% of reasonable and customary charges after my initial deductible of about $350 (2011).

Are you on regular Medicare or an Advantage plan as secondary? Maybe during open enrollment this fall, get an Advantage PPO plan as secondary and try in Jan.

Thanks! It's regular Medicare and I'll check on Medicare Advantage. Worst case scenerio I just wait until I DO get diabetes and/or high blood pressure since it is inevitable. Or self-pay and get financing.