Jump to content
×
Are you looking for the BariatricPal Store? Go now!
Sign in to follow this  
  • entries
    6
  • comments
    0
  • views
    497

Spooky Halloween Tales from the Darkside of Bariatric Surgery Appeals

Walter Lindstrom

86 views

The ghouls and goblins don't just knock on your door yelling "Trick Or Treat"!  They sometimes reside in the so-called "Customer Service" departments of health insurers, proving on a daily basis that they are not interested in their Customers and not usually capable of providing Service. 

413263890_customerservicerep.thumb.jpg.21023029637d89fcb707934527841f93.jpg

Quote

"Please understand that we are your health insurance plan - - we have special training in providing misinformation, acting incompetently, being argumentative and showing a complete lack of compassion or interest in your health. 

Now having said that . . . . . .How Can I Not Help You Today?"

 

We thought some of these stories, and we have oodles of them, made for an appropriately ghastly Halloween blog.  Make sure you read all the way to the end so you can see what the Devil has in store for some of these folks in the insurance industry!  

"I don't have to give you any information about your appeal!"

While this particular horror story involved an Aetna appeal years ago, problems like this happen all the time and we still can substitute the name of nearly every other major insurer for Aetna  and have a similar tale to tell.  Kelley was following up on an appeal we filed and was requesting confirmation that things were in process and inquiring about the status.  The "Customer Service" person simply refused to provide any information despite confirming were the appealing patient's representative.  So what......she just wasn't going to give any information to our office.

Many reading this will know how incredibly nice Kelley is.  If you don't know her then you can be certain her reputation for patience in matters like this is beyond dispute.   Since this representative obviously wasn't going to budge Kelley calmly requested to speak to a supervisor.  That's when things got interesting.  The representative refused to transfer the call, stating the issue "did not rise to the level of involving a manager."

A full thirty minutes later,  after repeatedly demanding to speak with a supervisor and ultimately threatening to file a complaint with the Massachusetts Department of Insurance, Kelley was finally transferred to a Supervisor's voicemail, who got an earful of "message" from our office concerning what occurred.  Kelley suggested the Supervisor listen to the recording of her exchange with the service representative because (don't forget) "this call may be recorded for quality assurance purposes."  When the Supervisor called Kelley back she profusely apologized and confirmed the customer service personnel are required to transfer the member to a supervisor immediately upon request and that the representative was way out of line.  The happy ending to the story is ultimately that Aetna approved the RNY gastric bypass that was the subject of our appeal!

"I'm sorry but you don't have any right to appeal or obtain an IRO of this denial."

There are some insurers who try to eliminate patient rights to appeal, especially appeals occurring before the surgery takes place.  Some denials are labeled as coming from "courtesy reviews"  with no appeals available.  (I personally find it interesting they use the term "courtesy review" when they rarely do much of a "review" and hardly ever show any "courtesy" . . . but I digress. . . .)  BCBS of Alabama is among a number of payers who sometimes try to bar appeals.  It is very rare that appeals are not available prior to having surgery so don't just accept their statements as being true

We know when they are playing games and most of the time companies (like BCBS of Alabama) end up processing the appeal and when (shock of shocks) they tell us the member appeal was denied, we request an "external review."  BCBS of Alabama, of course, has an unusually high level of incompetence so we should not have been shocked their response was that the member actually did not have external review available because the denial we received resulted from (you guessed it) a "courtesy review."  Unbelievable!

Enter Kelley (you'd think these companies would know better) who spoke to 2 different Supervisors about the situation, each of whom provided her with different (yet both still INCORRECT) stories about the nature of the member's rights.  After spending one hour and 10 minutes on the phone Kelley was finally transferred to an "Operations Manager" who was truly horrified at what occurred.  She immediately initiated an expedited IRO request and 7 days later our client was approved!  When the dust cleared Kelley and the Operations Manager had a conversation and she again apologized for all the misinformation which was conveyed and assured us that they were using this case as a "teaching example" for their customer service personnel.

 

"You didn't think that just because we APPROVED your surgery after your appeal

we're actually going to PAY for it too, did you?!?"

It can be truly horrifying for the physician and facility to not get paid after successfully getting an approval.  Worse still are patients like us who fear getting HUGE bills even though we thought everything was settled after "winning" a pre-surgery appeal.  This can happen, usually when the maze of insurance company Departments fail to update their systems to show things were approved.  We sometimes need to go back to a payer, even after a successful appeal, and re-start the battle.  It can time time, patience and knowledge to successfully navigate the insurer's system to get this fixed.  Fortunately every time this happens we have gotten these claim denials resolved and re-processed for payment before the providers and patients turn into angry villagers storming Frankenstein's castle to chase these Monsters for the payment they are due.

So as I wish everyone a safe and happy Halloween, I offer special greetings (and a warning) to insurance company executives and their customer service representatives who seemingly delight in making patients and providers miserable.  They need to stop now.  Special-place-button1-294x300.jpgA number of years ago, at the Obesity Action Coalition's first Your Weight Matters conference, my costume included a button warning those in the insurance industry who do not change their ways. . .Hopefully they listen!

Walter-Is-The-Devil-258x300.jpg

HAPPY HALLOWEEN!!

 

photo.JPG

Walter Is The Devil.jpg



0 Comments


Recommended Comments

There are no comments to display.

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
  • Recent Blogs

  • Blog Comments

    • Hi I had my surgery in April 2018 I had a lot of experiences like you. Before my surgery, I used to gulp down some water. That was my favorite drink. Since the surgery it's been really hard to get water down. My doctor said many have that problem because water is heavy. That's one problem I didn't think I would have. I'm not the one who like a lot of artificial sweet drinks. Definitely not drinks with aspartame. I would do some drinks with suraclose. like the zero calorie powerade. It's pretty good and goes down well. I drink teas and coffee as well and add stevia the natural sweetner to try to get in all my liquids. So liquids have gotten better for me after 7 months. Hope it gets better with you
    • I'm kind of surprised that only about 30% are diagnosed(?) with an ED. I personally think everyone who needs WLS has severe problems with eating/food - if one wants to call that an eating disorder or not doesn't matter in the end.
    • My team is so weird. Full liquids are their own thing, and then purees and soft foods are thrown in together. I'm on that stage, which starts with cottage cheese and yogurt and ends with ground meat and soup/chili. The most "advanced" thing I've eaten was a couple (1 and 3/4 :)) of Ikea meatballs, which sat really heavy, but besides those, I'd say I'm around the middle of the list. Very moist tuna salad is fine, as are scrambled eggs (I mean, those settled weird, but I digested them, so I guess they're OK). I'm thinking of trying thin-cut lunch meat next; that sounds really good to me. All I want in this world is the middle of a cheeseburger--I could let the bread and veggies go; I just want some ground beef, and cheese on it would be excellent--but I know not to push things that far, yet. The reward for going slowly is not getting sick, and that is a very compelling reward. :)
    • Thank you for sharing your experience! I haven't even thought of trying to get my fluids in any form other than plain water or at a temperature other than room temp, but I may have more success there, as you have. I'll give tea a try - thankfully I enjoy my tea unsweetened! You're probably right about the rollerskating - I don't normally fall, but it could definitely happen, especially since I haven't skated for a month. I just love it so much, I'm eager to get going, but it's more important to let my body heal. I could make a point of taking a short walk during my breaks at work. Have you started soft foods yet, or are you still doing full liquids/purees?
    • Just comparing notes, in case it helps... I still can't drink plain water. I'm getting 90% of my hydration with hot tea (mostly decaf--I don't count the caffeinated tea toward my total) and protein shakes. And it is close to 64 ounces per day, but it's not ever very much more than that. Besides hot tea, I can stand to drink protein shakes cold or at room temp. Room temp Powerade Zero is only a little bit harder than a protein shake, but room temp water hurts. Cold beverages also do OK, mostly--it's chilly enough out, now, that I just find myself gravitating toward the hot--and I definitely eat more sugar free popsicles than anyone should (even though it's cold, yes ... they seem to help when I start to feel nauseated from dehydration, though, and also they taste good 😁). I think not going rollerskating (or ice skating?), this soon, might be better than going, unless you're a lot less likely to fall than I am. (Who isn't, though? 😁) We're still pretty early on in the healing process. I do little walks most days, and since I'm still on blood thinners, I figure I also still need to be up and moving a little bit every hour I'm awake. But none of it is especially epic exercise, and I'm not going to beat myself up about that until after I've been cleared to go in the pool and lift weights and get out of breath. (Those first two happen at the 1 month post-op appointment, and the latter, I don't know? I have in my notes, from somewhere, that we're supposed to exercise only at a "moderate" pace until sometime after the 6 week mark, but that's not from my surgeon.) I don't know what to say about the food. I feel so bad if I eat too quickly that it's a pretty good policing mechanism. Like you, though, I wish I'd practiced more. The constant gurgling has gone away, and now I feel hungry 3-4 times per day, like you'd expect. It probably helps that very little of what I'm eating now is so appetizing that I feel rushed to eat it, lol. I think this will all get better with time. I hope you find a way to get your liquids in soon, though! ❤️
  • Together, we have lost...
      lbs
    ×