Sunyinflorida

As mentioned in my profile, I currently have a lapband in place. I am having complications so I am looking at my options, along with familiarizing myself to my ins co requirements. However, I also know my surgeon's staff have the approval process down pat. They had my lapband approved in one day. Even the legal advocates like Lindstrom will say one of the top reasons procedures are denied is not meeting criteria or not providing sufficient documentation. The insurance industry is so heavily regulated by both the state and federal governments, that neither would allow the nefarious process of compensation based on denials. I, too, have been in the insurance industry for almost 30 years. I have assisted folks in understanding their Bariatric benefits and what materials they need. I have seen the lack of the dr office not wanting to provide that info and dealing with frustrated members. I'm fat,too, so, my empathy is with the member. I helped them finally get their surgery covered and didn't get fired for getting the surgery covered and costing money! Instead. I got a pat on the back for helping our member and making them happy.

No one is paid to deny your claims. That is nothing but a myth. Most insurance companies have clinicians, i.e., doctors and nurses, that make up their clinical review units these days, too. Most states require that someone Medically trained make these decisions. The criteria used to make the decisions aren't pulled out of some insurance wizards closet, either. The criteria is based on what the Bariatric surgeons professional society suggested standards are and those used by the profession. SO, if you are being denied, either you just don't meet standard, safe guidelines, or the material provided for the review was not clearly supporting that you do meet it. Find out exactly what they need and make certain it's being provided. If they say they need chart notes, get copies. Don't rely just on a letter from a doctor stating its medically necessary. When you claim repairs on your auto, you show the adjuster your car. Your chart notes are the equivalent to that.