United Healthcare Delaware. In-network doctor, out-of-network hospital. Help?

[melissamaho]

Just the facts - United Healthcare Delaware, 3 months into a 6 month pre-op diet and multidiscipinary program as required by the insurance company (to preface the rest of this, my surgeon is good, pro-DS and has been gung-ho about doing this surgery on me because of my coexisting conditions and high BMI/younger age, including having me get DS bloodwork to address all deficiences now, getting me to his DS support group and his DS nut, and I fully trust that his mistake was an honest one and not a bait-and-don't-switch tactic so I am not interested in having that discussion.) Today while discussing the surgery he took a glance at my insurance info, pulled me to the reception desk and confirmed with the coordinator that while he is in my network, the hospital he does DS at is NOT (he works at two hospitals, one in DE and one in MD, I am in DE, the DS hospital is in MD. He does not do DS in DE... why, I don't know) I truly believe that this was miscommunication between doctor and front desk, since "Delaware" was not specified on my paperwork, only UHC, and he has a lot more MD patients than DE and likely just assumed I had MD insurance without confirming it with them or me. Since he is the only DS surgeon in DE and I must be in-state, this puts me in a bind. My options are A) push, beg, argue to have the surgery here in DE and be his Patient Zero at this hospital (unlikely since he presumably has a good reason for not doing DS there, but during our conversation after this discovery, he seemed to be considering it... who knows) or B) fight the insurance company to approve out-of-network hospital care based on the benefits of DS vs. the other WLS procedures for my particular situation. How would I even start this process? I'm lost. I'm 3+ months from even submitting for approval. If there is a chance of getting this approved, I'll do whatever is necessary, but I feel pretty hopeless right now!

 

[Walter Albert]

keep in mind that you did not get fat overnite, so you need not get surgery yesterday, stick with your plan , make it happen YOUR way,,, you will live with the results for the rest of your life.

 

[DianaCox]

Start the request right now with UHC. Tell them you need to get the waiver in place NOW, so things can move quickly when you meet the other requirements. INSIST that they address this now, so it does not become yet another medically and scientifically unsupported delay as expressly determined by numerous studies and as held by the ASMBS guidelines, which the UHC policy violates, and thus is NOT within the standards of care prescribed by the pre-eminent medical society's guidelines: http://asmbs.org/2012/01/preoperative-supervised-weight-loss-requirements/

 

[DianaCox]

Wait - Maryland??? PLEASE confirm this is not Schweitzer!!

 

[melissamaho]

Wait - Maryland??? PLEASE confirm this is not Schweitzer!!

No, not Schweitzer. Sofronski at Delmarva Bariatric. Thank you for your help, I will be contacting the insurance co. first thing tomorrow morning to get the ball rolling.