When you call the insurance...what do you say?

Plusizeteen · 12-01-2006, 07:26 PM

So I went to my first seminar, and they stressed to make sure you call your insurance and see if they cover. They also said see if you need a supervised diet, ect. WELL...My insurance covers WLS for morbid obesity. NOW!:) What do I say? Do I give them the CPT code? Do I tell them my BMI? What do I say?

Thank-you so much for responding/ or viewing my topic!:clap2:

ReneBean · 12-01-2006, 07:29 PM

Well - if you already know they cover the surgery in general - you need to see if your employer has a specific exclusion.

You can either contact your HR dept and ask them - or you can call your insurance carrier - give them all the numbers they ask you for, and ask them if your employer has an exclusion.

Your best bet is to check with HR and your insurer. I got a different answer every time I asked... It took a week or two just to determine the correct answer.

Good Luck!

JDru · 12-02-2006, 01:44 AM

Like ReneBean said, your insurance may cover lap-namd generally, but make sure that it is covered under your specific benfits. My insurance didn't ask for a CPT code. The person I talked to looked up the specific criteria for people who qualify for bariatric surgery. I have Aetna and they required certain blood tests, BMI of at least 35 with co-morbidities, psych test, nutritionist eval and a medically supervised weight loss program for at least 6 months. I also had to get copies of a lot of medical records and that was the most difficult thing. I swear it's like pulling teeth to get records. Also, make sure you make a note of the date you called and who you talked to in case you have any problems with approval later on.

TracyinKS · 12-29-2006, 02:14 PM

From your screen name.. are you still covered under a parents insurance or are you gainfully employeed with your own?

Don't be shy when trying to find out info..... if you call your insurance company ask them WHAT EXACTLY do they need for your/your parents company SPD to approve the procedure.

Also, start by finding out if you have any bariatric surgeons IN network of your insurance.. go with them first, because if they are a provider for your insurance company they will know better how to deal with them.. but getting info from the HR Benefits person is KEY... get to the bottom of any exclusions FIRST.

GOOD LUCK

kyethra · 01-26-2007, 09:10 PM

I've called my insurance on a few different occasions. I first called to see if the surgery was covered and what they required. Did they require a physician supervised diet for any length of time, etc. My insurance said they do cover it and they don't require the physician supervised diet and there isn't any specific formula or process they have. Just that they look at each person on a case by case basis and then a committee decides. So they had requirements (other than the standard BMI ones) officially, but they did want to make sure surgery was apropriate for people and weight loss couldn't be achieved other ways. I had already started on a physican supervised diet anyway at that point- I don't think it will hurt. And my BMI is about 41 I think and I have other issues that are related to the weight- I have fibromyalgia, GERD, and an entraped nerve ending in my abdominal wall. And I've been on all sorts of diets and seen nutritions over the years. So it was all submitted to my insurance after my physc evaluation. I called my insurance a couple of weeks ago. I said, "I'm calling because last month a request was submitted on my behalf for the lap band procedure. When can I expect to find out if I have been approved?" They took my name and number and that stuff and said it would probably be a couple more weeks. Its been, so I will again Monday and ask the same thing. Say please and thank you and be patient with whoever you get.

janiee · 01-27-2007, 01:12 AM

I have an HMO, so my primary doctor sent in a request for a bariatric surgery consult. I was denied because I needed to do 6 months of supervised diet. I called my Ins company to see if there was anything else I should be doing and the woman said, "I don't know"...I have questions but they don't seem to have any answers

lizrbit · 01-28-2007, 11:12 AM

dont give up. Its your insurance, that you pay each month for.
dont give up at least not without some answers.
and then dont give up, most surgeons have self pay financial options. (see how easy i said that? if my insurance doesnt approve i dont think i can qualify for self pay due to my current finances...but i definately have to try)
call them back, sometimes they can assign you a 'case manager' (free with your insurance) and their job is to get it all in one unified order, and be the person who can answer questions. I do know that you start with your primary care physician. Get his/her support first, then they are to submit a letter of referral describing 'medical necessity' to your insurance.
Im nervous about a possible wait. ive done alot of the work already and im ready to go!
Good Luck to you (and to me too).

lizrbit · 02-02-2007, 11:29 AM

i got notified via my pcp that my insurance has denied my first claim. i didnt have all my records there when submitting the first try so i knew that it wasnt likely. I havent even met with the surgeon yet. Ive met him at the seminar but my first appointment in his office is Monday (feb 5). I was told their office handles all insurance stuff, so im hoping im just ahead of the game and that the game isnt closed yet. After what I posted here last, I had to come back here and post this experience. im not giving up yet. Im going to wait and read why it was denied, im going to talk to the surgeons office about it, and go from there.
i'm a little bummed by it, i gotta tell ya...but im not giving up yet.

MEW · 02-02-2007, 04:03 PM

Dont give up lizrbit....its a waiting game. If your surgeon's office is willing to handle the insurance part of it, let them, they should know exactly what it is you need to submit to the insurance office, but keep yourself informed!!
Before my insurance will even consider a yes/no decision, I have to have a letter of neccessity from my PCP, a letter from the surgeon, a psych eval and nutrition consult turned into them first. (My insurance will pay for psych eval and nutrition consult since they are the ones requiring it) I attend my first seminar Monday night, (Feb 5th) and will take it from there.
I wish you lots of luck!! Keep us updated on what you find out!! I'm pulling for you!!!

**LaP HaPPy** · 02-03-2007, 01:50 AM

DONT MAKE THE SAME MISTAKE I DID!!! A PHONE CALL IS NOT ENOUGH!!!

I know we all have had issues with our insurance companies, but my United Health Care company has truely deadened my spirit. On 4 different occasions I called to see if Lap Band surgery was covered, and 4 different people told me it was, following a medical review. I completed all of the necessary evaluations (psych, nutrition, diet history, etc) and sent the info off for review.

I called on 1/13 and was informed that it was declined for lack of coverage. I was so stunned, I just hung up the phone.

I called back on 1/15 to find out how this could have happend and was told that it was an error, and they would send it back for an urgent review.

I called back again on 1/16 and was told the review was denied again and that I do NOT have coverage. I told her about the 5 other times someone have confirmed coverage,and she said that they were not following the proper procedure in looking up obesity surgery. She told me that it is an exclusion in my policy. She gave me the address for an appeal, but told me that it was not likely they would change their minds.

Needless to say, I am completely devistated. I am not only out the $500 I have spent so far, but more importantly, struggling to think of ways to get the 15K for the surgery.

I am seeking your advice! Anyone have something like this happen to them? Was it worth the time and energy to fight the insurance company? I was told by my doctor that fighting an "exclusion" was more with your employer, and I can only imagine what that would be like. (my hubby works for state government)

I am just looking for any info you guys might have. Thanks so much for your support!

Niki

lizrbit · 02-05-2007, 08:37 PM

so!
Today i met with the surgeon at his office. He knew all about my case, and was really informative. I went over my insurance problems with their office folks who handle this stuff, and this is what i found out...
my insurance did NOT deny the surgery, they denied the out of network referral for the office visit. Not a problem they said. While i sat there, she got on the horn with my insurance and they are all over it.
Im supposed to get a call...dont know when, but they will...and let me know whats up?
so...i wait.
I really really like this surgeon. He was to the point and answered all the questions i had without me even asking them.
Im going into waiting mode. Ive lost another five lbs. Im worried about suddenly being approved and having to fast to shrink my liver, so im doing what i can to get ready. IF I DONT have this done, i KNOW it will just come back on, probably within a month...but im trying to be ready.
so i wait.

MEW · 02-06-2007, 01:07 AM

The surgery itself hasnt been denied...so thats great news lizrbit!!!

janiee · 02-06-2007, 02:10 AM

What great news Lizrbit!! I will be crossing my fingers for you that everything goes real smooth:)

lizrbit · 02-07-2007, 09:53 AM

thank you so much! you know, its really awesome to talk about this stuff with people going through it too. i love this board.
Maybe the waiting game wont be so long...

in the meantime..its around seventy degrees here :)
sunshine!
birds singing!

**Wheetsin** · 02-07-2007, 10:53 AM

Re: exclusions - what you've been told is correct. An insurance company offers a variety of services to the employer, and the employer picks & chooses what they want (based largely on cost). A lot of employers will decline the bariatrics because of the cost to them. When the employer declines it, it's an exlcusion.

Fighting an exclusion with your insurance company won't do any good. That service hasn't been purchased, so they will not provide it.

Exclusions are employer choice. So if you want to appeal an exclusion, your best bet would be to talk to the benefits admin at the employer company. Chances aren't great that anything will change, especially with an employer as large as a state function, but you can always try.