I Was Preapproved And Now After Gastric Sleeve Surgery Insurance Is Denying Claim. Beware!

[njjewing 1]

OMG.... this just happened to me today! I went into my dr for a 3 week follow up and my nurse found me and told me that she has been arguing with my ins co AETNA for 2 weeks now because they are saying that my sleeve wasnt covered. I have the mailed approval letter, my nurse has a digital copy of it along with my precert confirmation #. AETNA is saying that it wasnt precertified so I am confused. I had some complications with my surgery and had to stay 4 days in the hospital so my dr, the hospital room, drugs, anesthesia, etc total comes to a little over $70,000. I sure hope they figure this out soon!

[Norman 1]

One of my family members is a bankruptcy attorney and I have talked to her about what I should do if the insurance does not change their mind. Good luck. Bankruptcy might be our only option.

[Tai29 17]

@ Njjewing

Did Aetna say why this was denied?

Were the CPT codes submitted to preauthorize the sleeve the same codes submitted during billing?

Sometimes we have issues with precertification stating it was never obtained due to an insurance compang internal system issues not attaching the authorization number automatically to the member file and/or claim.

It's best to get involved and find out the exact denial reason to know the next steps you need to take to have them reconsider the charges.

[RSREED53 4]

Njjewing, I would be in the middle of Aetna with my approval letter and ALL documentation for their approval regarding your sleeve--get an atty if they renege on their commitment to your care coverage because what they are trying is a scare tactic because of your complications and a higher bill. Don't let them get away with that! Now is not the time to back down from them. I am sure your doctor's staff will help with any and all paperwork needed to clear the matter up--also, I bet somebody mistyped codes and faulted on the clerical work during claims processing. It happens. Best of luck to you, and I hope you are having better success with your new sleeve. Ronda

[5DogMa 62]

Working for a hospital that is also a premier bariatrice center of excellence, I see this all the time. BCBS is a main offender. As the patient, I will reccomend that you stay on top of them because they quite frequently say they will reprocess something and it will go into the Anthem black hole and when you follow up you will learn they really have done nothing with the claim. Also, I would suggest finding out WHY they denied the claim. It is also important to note, the pre-approval is not a guarantee of payment. The insurance company determines payment eligibility upon receipt of claim, and surgery notes, etc. They are under no obligation to pay for your medical services because you received a preapproval letter. Frequently we will receive precertification for inpatient hospital stays, only to have them denied once we submit the claim. We end up going through appeals processes to overturn their original denials. Insurance companies are very ambiguous in their wording so that if they do decide to deny something, they can site the technicality in the letters to you that will allow them to not do so. Also, what someone else said is true too - your benefits are ultimately determined by your group (employer). Companies buy insurance packages that are one size fits all, and they in turn distrubute them to their employees. The company you work for determines what they would like included in the benefits package and sometimes costly procedures are nixed for budget purposes.

YIKES! So does that mean your employer knows that you are having WLS? I thought this stuff was confidential.

[former_vbg 198]

Just because the employer gets to tailor the insurance package given to the employees doesn't mean they have access to confidential medical files. One does not equal the other. It's simply stating what benefits you WILL or WILL NOT have access to in accordance with the plan they signed up for. It is a violation of HIPPA if your medical records are given out to anyone without your written authorization, short of a court order for legal reasons.