Unbelievable insurance actions

[Jennie1980]

I have United HealthCare Community Plan as my secondary insurance. UHC is my state's Medicaid. My primary excludes all bariatric surgery. In August 2015 I started my journey by attending a seminar. The office of my surgeon suggested switching from Blue Care to United HealthCare as they said it was easier to get approval with UHC. And frankly, they pay better. I had just missed open enrollment. I'm a lightweight but I'm very sick. I have 5 of the 6 comorbid conditions that my insurance considers for approval. I began doing the required 6 months of supervised dieting in anticipation of switching to UHC in July of 2016, during open enrollment. I did everything required of me by that time and made the call, got switched and was told the change would be effective September 2016. Submitted and was approved. In the meantime the office I am using raised their fee for non covered services. I was saving up. Meanwhile, my approval expired in December 2016. I didn't know this until I was about to pay the fee. No big deal, I was approved once on the same exact information. Well, they denied me in February. I appealed and they denied me again. They listed the reason as not medically necessary because no information was sent that told my BMI, listed any comorbidities, stated I had done the 6 months dieting and had the psych eval. Non sense. So we appealed and sent all of that information again. I was denied again. The said that even though I have the required BMI that I needed to send 6 months supervised dieting, psych eval, and proof of comorbidities. Only this time they listed very specific information such as proof of my blood pressure and that I'm taking medicine for it. They acknowledged that I use a CPAP but they want they the actual report and listed a certain number they require the AHI to be. I guess my primary doctor's word isn't good enough. She has sent them a very detailed letter regarding all of my comorbidities and my dieting. I've never seen my actual sleep study report. I have no idea if I met the requirements as I don't know what my AHI number is. UHC pays for my blood pressure medicine, my cpap supplies, my metformin, my cholesterol medicine and my multiple musculoskeletal medicines. I'm just stunned that they're giving me such a hard time. My surgeon's office has never seen anything like it. It's extremely frustrating because I've been working at this for a long time and I gathered very detailed information about what they required for approval. Then I went down the check list and accomplished/proved everything they were expecting of me. I'm at a loss. Of course I will keep fighting but I feel like I'm being unfairly targeted. Have any of you all had any experience with anything like this? I'm wondering now if maybe I shouldn't drop the appeal process, wait for the time to lapse for that and then just resubmit a new request. The surgeon's office says that will take months. But when I suggest that Dr. Boyce just call in and do and peer to peer review, they act like I'm asking him to donate his kidney to me. It boggles my mind. They let thousands of dollars slip through their hands over $1,500. That's odd to me. And even though I do believe they sent the necessary paperwork all along, that they aren't very aggressive in getting they he job done. My BMI is 36. I have musculoskeletal diseases made worse by my weight. I have sleep apnea. I have ridiculously high cholesterol and the medicine hasn't helped over a 2 year period. I'm pre diabetic and on metformin. The insurance office told me before that if I was on medicine for pre diabetes that it counts as type 2 diabetes. I have high blood pressure and take medicine for that. All of which UHC pays a portion of these medicines and treatments. My letter from my primary doctor was remarkably well done. I did the 6 months dieting. I did the psych eval. That's about all I can think of right now that they required. The only comorbid condition they list that I don't yet have is heart disease. They told me in the beginning a bmi of 35 with TWO comorbidities. Now they say only one is required. Apparently my 5 are not serious enough. And I don't know if they don't realize they approved me a few months ago or if they're just enjoying effing with me. Any thoughts or suggestions?

 

[Larra]

Do you have your EOC? You have an excellent knowledge of their requirements for bariatric surgery, but we also need to know your appeals rights. If you have exhausted all your internal appeals, hopefully you also have access to external appeal, and with the serious and well documented comorbidities you have, you should win on external appeal.

 

[Jennie1980]

I've tried to get an EOC when I first started this, based on things I've read here. It's like pulling teeth. But I'll get back on that come Monday morning.

 

[galaxygrrl]

Hang in there and good luck Sorry it's been so hard

 

[Larra]

@Jennie1980 at this point, even if you can just get the section on appeals that would be a huge help.

And a question for @southernlady - you know Dr. Boyce. I don't. This is the second issue we've seen with him or his office recently, first @writegirl not being informed about her insurance requiring bmi over 60 for the DS, now an apparent reluctance, if not unwillingness, for Dr. Boyce to do a peer-to-peer. While I agree that it shouldn't be necessary for him to do this, given Jennie's obvious qualification for the DS, and I'm sure he's busy, but really, we're talking about a 15-20 minute phone conversation, if that. Is he really someone who wouldn't do this, or is it that his office staff is being overly protective? if you know, that is. Thanks.

 

[DianaCox]

I wonder if there is an ombudsman in your state's Medicaid office?

 

[southernlady]

@Jennie1980 at this point, even if you can just get the section on appeals that would be a huge help.

And a question for @southernlady - you know Dr. Boyce. I don't. This is the second issue we've seen with him or his office recently, first @writegirl not being informed about her insurance requiring bmi over 60 for the DS, now an apparent reluctance, if not unwillingness, for Dr. Boyce to do a peer-to-peer. While I agree that it shouldn't be necessary for him to do this, given Jennie's obvious qualification for the DS, and I'm sure he's busy, but really, we're talking about a 15-20 minute phone conversation, if that. Is he really someone who wouldn't do this, or is it that his office staff is being overly protective? if you know, that is. Thanks.

Larra, he's never been one for hands on esp relating to insurance issues. His staff has a standard playbook regardless of your personal EOC. We ran into that with dh's insurance back before we both fired his partner, Dr. Williams.

 

[Jennie1980]

Diana, that's a brilliant idea! Thank you!

Southernlady is right. They have their play book and seem stunned when there's a curve ball. The lady who got me approved initially was an exercise person, filling in for the insurance person who was on vacation. She's aggressive. The actual insurance person, not so much.

I am puzzled by the folks in that office, including the doc. On first glance he seems like a real go get er. You hear from multiple former patients how fantastic he is, in every sense. You hear how awesome the office staff is. You hear how they all go above and beyond to accommodate everyone. Aggressive, knowledgeable, fast, caring, blah blah. Apparently, I'm the only person in the world who hasn't had that experience. But he's an excellent surgeon and I want him to do my DS.

Thanks for the ombudsman suggestion. I had actually considered calling my state rep. I may just do both.

 

[writegirl]

Diana, that's a brilliant idea! Thank you!

Southernlady is right. They have their play book and seem stunned when there's a curve ball. The lady who got me approved initially was an exercise person, filling in for the insurance person who was on vacation. She's aggressive. The actual insurance person, not so much.

I am puzzled by the folks in that office, including the doc. On first glance he seems like a real go get er. You hear from multiple former patients how fantastic he is, in every sense. You hear how awesome the office staff is. You hear how they all go above and beyond to accommodate everyone. Aggressive, knowledgeable, fast, caring, blah blah. Apparently, I'm the only person in the world who hasn't had that experience. But he's an excellent surgeon and I want him to do my DS.

Thanks for the ombudsman suggestion. I had actually considered calling my state rep. I may just do both.

You're not the only one @Jennie1980 -- I'm less-than-impressed with the way Boyce's office "informed" me, after 7 months of MSD and psyche eval, expenses, etc. that they just now figured out that my insurance (which I have had since day one there) requires a BMI of 60 for the DS that Boyce recommended for me and that I've been working toward since that recommendation. I'm kind of floored, while hoping for the best outcome.

Interesting tidbit: His insurance office manager told me that if/when I am denied for the DS that Dr. Boyce can do a peer-to-peer review. So, apparently he does do those when necessary. Either that or she was blowing smoke up my ass about it because I let my displeasure at their incompetent handling of my insurance and what I qualify for be known.

At some point, I will let Dr. Boyce himself know how frustrated I feel about this. I would rather have my surgery first, though. I do feel lucky to have him as a surgeon and I'm trying to see this craziness as the honest mistake it probably is, but that said, there should be these kinds of mistakes from an office that caters to WLS and does however many hundreds of them a year.

 

[Jennie1980]

@writegirl I'm so sorry you've had to deal with this. They first told me they didn't accept my secondary. That was in August of 2015. That following January they began taking it. They didn't inform me until I had waited until July so that I could change insurance to what they did accept. Blue Care being what I had originally. United HealthCare being what I switched to. That was an 11 month wait that could have been reduced to 4 months and no need to switch carriers. Meanwhile, I switched and they were glad of it because United pays better and according to them, approves easier and faster. What they didn't mention at the time of submission was that my fee for "non covered services" increased by $500. I wish I had $1500 just laying around but that's not the kind of life we've been living lately. So here I am, with my money for the fee and a denial from insurance. I am still pretty stunned. Tried to nap today and couldn't clear my mind of thoughts about insurance approval. I hate to say it but it's crossed my mind more than once that if my BMI went up to 40, I'd be approved, no problem. I know that's crazy thinking but I'm desperate to feel better. @writegirl , what recourse do you have? Will this be something you can get worked out?

 

[writegirl]

@writegirl I'm so sorry you've had to deal with this. They first told me they didn't accept my secondary. That was in August of 2015. That following January they began taking it. They didn't inform me until I had waited until July so that I could change insurance to what they did accept. Blue Care being what I had originally. United HealthCare being what I switched to. That was an 11 month wait that could have been reduced to 4 months and no need to switch carriers. Meanwhile, I switched and they were glad of it because United pays better and according to them, approves easier and faster. What they didn't mention at the time of submission was that my fee for "non covered services" increased by $500. I wish I had $1500 just laying around but that's not the kind of life we've been living lately. So here I am, with my money for the fee and a denial from insurance. I am still pretty stunned. Tried to nap today and couldn't clear my mind of thoughts about insurance approval. I hate to say it but it's crossed my mind more than once that if my BMI went up to 40, I'd be approved, no problem. I know that's crazy thinking but I'm desperate to feel better. @writegirl , what recourse do you have? Will this be something you can get worked out?

I hate to say it, but I'm now not at all surprised that they failed to mention those fees to you. Just like they failed to mention that my insurance would not cover DS unless my BMI was 60--for the past 10 months of dealin with them. I was denied by my insurance. Waiting to see if Boyce can get me approved with a peer-to-peer review. The patient "advocate" has been defensive and argumentative. I don't feel advocated for at all, tbh. I hope things work out better for you.

 

[Jennie1980]

@writegirl I'm at the end of my rope with these people. My insurance sent specific numbers that my apnea has to meet. And asked for a copy of my study. I had my sleep medicine doctor send that to the Pre-d coordinater at Boyce's office. "The insurance person" I knew my numbers on this study did not meet the amount they required. I call and told her it did not. She basically said, to bad. Done sent it. We will wait for the denial and appeal. I told her that my cpap machine tells me I meet those numbers and that I need an updated test. Mine is 2 years old and I've gotten significantly worse. She said no at first until she realized she could have it done and bill my primary insurance. My secondary wouldn't cover it through them. So then she was like well if they deny this appeal, we will do the test.

Today I got a letter telling me my appeal is going to the legal solutions unit for a fair hearing. It's going to that unit with incomplete and wrong information. They'll send another letter to give me the date. I tried to call the pre d person. She's out sick. I tried to get Boyce's nurse to call me and get the damn test ordered. Didn't bother to return my call. It's important that this test be done before that hearing.

This could have all been solved very easily with a peer to peer review. But I can't get to doctor Boyce to speak to him about it. They people who are supposed to communicate these needs to him, act like I want his kidneys or something. I mean she acted like it was an absurd request when I told her that my insurance rep told me the best and most efficient way to handle this and get it approved was for him to do the peer to peer. In the mean time, I'm getting sicker and sicker and can't even get a call back.

I spoke with insurance again today. The person was just dumbfounded by the fact that it was approved and then denied with the same exact facts. Then when she went over the requirements and realized their own notes say I meet everyone, she didn't know what to say. Once again I was told that someone from the office needed to call and ask exactly what is missing or needed to get it approved and if they have everything why was it approved once and not now. Of course when I called to speak to someone at Boyce's office they're closed. I have half a mind to go down there. I swear the pre d person acts as through she's terrified to just call them. I could just cry. But I will not give up.

 

[Jennie1980]

I'm sorry for the novel, ya'll. I'm having a bad day. I don't feel well at all and I'm frustrated to death. Thank you all for listening

 

[Jennie1980]

So one the most recent denial letters said I needed the copy if my sleep study results and that this results had to show an AHI reading greater than 30. My study is more that 2 years old and I'm much worse with the AHI readings on my machine showing sometimes 67 or more. I knew my old study would not show 30 or more AHI. So when I realized this, I called the pre d person and told her this and asked if they could order a new study. She has no idea what I was talking about. She fumbles through the letters and so oh yes your right and no your numbers aren't high enough but it's already been sent so we will wait for the denial on that. I asked can we not go ahead and do the new sleep study and send those updated accurate results for their consideration since we may have time. Nope. Wait for denial. Can we get the study done to have it immediately available when this one is denied. Nope. Let's wait and see. They also specified that having hypertension alone isn't good enough. My blood pressure must be at least 140 over 90 while medicated. She didn't bother to send the information regarding my blood pressure readings of 148 over 94. She's fixated on the apnea when I only need 1 comorbid condition to qualify. I have five for her to choose from.

So yesterday I got a letter from TennCare regarding a fair hearing. And that FedEx would bring a letter with the date, time and information. That I could have a lawyer and all that good stuff. They've never sent one like this before so I'm guessing this is the end of the line. So I called the office to once again ask about a sleep study so that I can have a full arsenal in this fight. No return call. Called the nurse to try to get it ordered. Also emailed nurse. No reply. Called the patient advocate, not a peep. Called pre d person again to day. Told her I needed the sleep study because we knew that one would not work. She argued that once the train is rolling, you can't stop it. I ain't trying to stop it. I'm trying to make the trip easier and more efficient. She acts like I'm speaking in unknown tongues. I asked about a peer to peer review again. You'd think I asked for her first born child. I told her that every time I talked to the insurance company they tell me that it would most likely be approved if a peer to peer happen. Especially since it was approved before - their words. She said well these letters don't mention p2p. I gave up.

She called back later to tell me the office manager said I need a new sleep study since mine is 2 years old anyway. But no so they can send it to insurance. Just because it needs done if I've gotten worse. Only they don't want to do it. Get someone else to. What in the actual hell? My primary insurance will cover it and they must forget that they won't have to bill my lousy medicaid for things like that. She said oh yeah I saw that those letters did mention p2p review but we need to wait for this denial letter. Am I allowed to cuss her here? Because I really want to. That place has turned into a circus and the left hand don't have a clue what the right hand is doing. I'm going to get the new sleep study done with someone else asap. I'll have it sent to Boyce and pray I can get them to send it in a damn fax.

On the EOC. No one at united healthcare has a clue what I'm asking for. I'm being to think I can't get that because I'm on state medicaid and not going through and employer. Advice @DianaCox or @Larra I'm going to post below my statement that I'll read over the phone for this hearing. Please let me know what needs tweaking. Thank ya'll for your time

 

[Jennie1980]

Weight loss surgery is medically necessary for me. I meet the requirements for approval for the reason that follow:

1. My BMI is more than 35. Documentation provided.
2. A BMI of 35 requires at least 1 comorbid disease. I have 5 of the accepted conditions as follows:
A. Hypertension not well controlled with pressures of 148 over 96. I have been taking Lisinopril for this
B. Obstructive Sleep Apnea, for which I use CPAP. (I'll update and include information from new sleep study asap)
C. Impaired Fasting Glycaemia with an upward trending A1C despite the use of Metformin.(doc app tomorrow, this will be checked and I have a feeling the AIC will be high enough. Update asap)
D. Hyperlipidemia which I've been trying, unsuccessfully, to control for years through diet and medication. I'm currently taking Crestor without success.
E. I have musculoskeletal diseases that do impair my daily living. I have Psoriatic Arthritis, Fibromyalgia, Sjogren's Syndrome which attacks my joints. (Having a new Ana tomorrow, believe I have lupus, will update)
I treat these with a multitude of medications & things like physical therapy without much success. I have provided the required information for these conditions.
*Everyone of these conditions would be greatly improved if not totally eliminated by weight loss surgery. Improving & potentially eliminating these diseases would save money for United HealthCare by greatly reducing the number expensive medications and supplies I require. And by reducing the number & frequency of tests and procedures that I am likely to need in the future. Being that I'm only 36 years old, those needs could be numerous and very costly.
3. I've done six months of structured physician monitored weight loss attempts and provided that documentation. I was not able to maintain weight loss. I've done calorie & carb restrictions, Atkins diet, Mediterranean Diet. I've done aquatic exercise & some aerobic exercises. To name a few. I'm limited in what I can do because of my musculoskeletal conditions & the pain they cause. That pain would be greatly reduced by getting the some weight off my joints via weight loss surgery, making it easier for me to exercise more. I am unable to take weight loss drugs such as a certain weight loss drug I cant say here, because of hypertension & because they are counter indicated for people with thyroid conditions.
4. I've had the required psychiatric evaluations & was cleared for weight loss surgery. I provided documentation for that.
5. I have attended weight loss support group. I provided that documentation.
6. My primary doctor recommendeds weight loss surgery for me because it is medically necessary. She cleared me for surgery. I provided that letter.
7. I do have incapacitation of my daily living because of my size. I need help with putting on my upper garments. Some personal hygiene needs can no longer be dealt with without assistance. I cannot do several if my household chores because of my weight. Frankly the pain & limitations caused by my weight are contributing factors in my lack of employment.
8. I understand the post op requirements of weight loss surgery & I am very willing to comply. I will follow the diet plan, I will participate in nutritional, behavioral & exercise counseling. I will follow the surgeon's instructions.
9. I cannot become pregnant so that will not be a concern during the rapid weight loss phase.
10. I am over the age of 18.
11. It's my understanding that Dr. Boyce supplied the documentation regarding my individual assessment, my physical exam, my pertinent medical history and my surgical history.

Weight loss surgery is medically necessary for me & I have met all of the requirements for approval from United HealthCare & TennCare.

In fact, United HealthCare Community Plan DID APPROVE me for weight loss surgery in September, 2016. That approval was based on the exact information that was sent again in February 2017 & was denied. Unbeknownst to me the approval United HealthCare gave me in September, 2016 expired in December, 2016 as I was saving up for the non covered services fee required by the surgeon prior to scheduling the surgery. Once I had the money for the fee & was ready to schedule, I learned that the approval had expired. So Dr. Boyce had his staff resubmit the same identical information in again but this time that information was denied.

I went down the list of everything they require for approval and everything listed on the denial letters that they want to nit pick about and I answered for each one individually. I thought about adding information about other comorbidities I have but aren't on their list of accepted ones, like PCOS, and a couple others that escape me at the moment. I've also thought about mentionin my family history which would indicate that my heart is a ticking time bomb that's likely to go off before I'm 40. Any thoughts would be much appreciated.