Hello everyone,

I started my sleeve journey in August, when I was told my insurance company required 6 months of work with a dietician, as I'm sure a lot of people here have experienced or heard of. I did all that, jumped through all the hoops, and was sleeved March 7th. Fast forward almost two months, I just yesterday found out my insurance company does not cover the sleeve (??????) and I've now acquired $65K in surgery bills. I called the insurance company and the man I spoke to said they only cover diagnostic fees that come with it (whatever that means) and that was the end of that. I called the surgeons office in tears, and they said they'd never heard of anything like this, but that they got their money so the letters I received from my INS company must be "erroneous". After speaking with them today, they told me that even though the insurance company had reimbursed them, they just found out today that they are asking for the money back, and that they are going to appeal it. WHAT DOES THIS MEAN?! Has anyone ever had any problems of this nature? I went from only owing $2500 in deductables to $65,000!! I could've gone to Mexico and had a sleeve vacation for $10K! I am so beyond upset right now, and feel like my insurance company is trying to ruin my life. Please, any advice/stories/knowledge would be greatly appreciated.

If you don't mind me asking what insurance do you have that did this to you??? this is horrible.

United Healthcare Options PPO through UMR.

If you are liable for the surgery, it would not be 65,000.00. It would only be the allowable amount the insurance paid. So, if they only paid 8,400.00 to the Dr. that is what you would have to pay them. I am a medical biller and I know this for a fact. You would not be liable for 65,000.

Also, you may want to look up the Insurance Commissioner for your state and write to him. I had to fight a denial of a personal claim for my daughter when she was a baby and I wrote to him and explained the situation and I won! The insurance company didn't what to pay stating that her condition was pre existing.

Good luck to you. Try to calm down and know that it won't be that much. If you do have to pay for it, the hospital and Dr's office will have to try and arrange a payment plan for you.

God Bless!

Time to lawyer up

Ditto.

In my healthcare experience, your doctors office should have done a predetermination. This is different from authorization. A predetermination would decipher 1. If the procedure your requesting is a covered benefit 2. If you meet the requirements for this procedure. Most hospitals will not do wls unless there is a pre-d on file. So first I would ask your surgeon if he has a copy of the predetermination on file. A pre-d comes directly from the insurance company, authorizations many times are out sourced, and done by a third party company that has no knowledge of insurance benefits. So for future reference I hope everyone understands the difference between both, As insurance companies are sneaky and will try to wiggle their wAy out of paying anything. So many times when you have a pre-d you may or may of also need to obtain authorization. Please be aware that pre-d comes from your claims dept and authorizations come from medical management, sometimes you may only need a pre-d, but that is not always the case. Hopefully ur doctors office has a pre-d on file. If not in my experience it is usually customary that the hospital write off the expense. However it takes a lot of knowledge and persistence to get them to do this.

Please do not hesitate to message me, I will try to help you navigate the system as best I can.

14 years healthcare experience.

All I have is a letter stating they found me to medically in need of the surgery, and that the letter is "not a guarantee of payment". That's all I ever rec'd from my ins co throughout this entire process (until, of course, it was over and they started sending me 'explanation of benefits' stuff). I (stupidly) assumed it was the surgeons' office job to get all this worked out, as they assured me they did. I was even told that they couldn't do surgery without ins approval.

PS - I'm assuming lawyers don't handle this kind of stuff for free, right? :-/

All I have is a letter stating they found me to medically in need of the surgery, and that the letter is "not a guarantee of payment". That's all I ever rec'd from my ins co throughout this entire process (until, of course, it was over and they started sending me 'explanation of benefits' stuff). I (stupidly) assumed it was the surgeons' office job to get all this worked out, as they assured me they did. I was even told that they couldn't do surgery without ins approval.

PS - I'm assuming lawyers don't handle this kind of stuff for free, right? :-/

The lawyer would collect fees from a winning verdict. Sometimes just the threat of a lawsuit will fix the situation..

Definitely contact a lawyer.

Did you get your approval or start your approval before the 1st of the year? I'm wondering if your insurance policy changed at the first of the year and now doesn't cover the surgery.

I hope it works out

This sounds like a giant mistake. I have United Healthcare for Railroad Employees and I was covered 100% for my surgery in April. UHC just began coverage for the sleeve in January 2012 so I'm hoping this is where the confusion is coming in. Maybe since it is a recently covered procedure the billing process is not up to speed with the changes in January. I suggest getting the info in writing as to when the sleeve became an approved procedure and then begin building your case with a lawyer.

Oh and forgot to add then when I began the process of researching the sleeve the first thing I did was contact my insurance the confirmed for me that it was a covered procedure. I didn't want to waste my time looking into it had it not been covered.

I haven't read through this entire thread so I apologize if my advice repeats someone else's. First, I would call the providers, all of them, and tell them not to refund the money as you are fighting this. Next, make sure you keep all your EOB's from them showing the payments. Then, I would contact the Department of Insurance in the state you live in to file a complaint. You'll be able to Google and find it. I work in insurance so let me know if you need help. By paying the bills, they've pretty much admitted liability and I'd be surprised if the Dept.of Insurance didn't rule in your favor. Good Luck and keep us posted.

~Amy

This sounds like a giant mistake. I have United Healthcare for Railroad Employees and I was covered 100% for my surgery in April. UHC just began coverage for the sleeve in January 2012 so I'm hoping this is where the confusion is coming in. Maybe since it is a recently covered procedure the billing process is not up to speed with the changes in January. I suggest getting the info in writing as to when the sleeve became an approved procedure and then begin building your case with a lawyer.

I was approved through UHC in 2011 but decided to wait until Feb so they may have covered longer in some areas. They did try to not pay part of my hernia repair saying it was medically unnecessary but my doctors office fought it and got paid.

I think keep calling the insurance co until you get some answers.

I have UHC and I thought they were not going to approve me, but the doctor's office pushed them. Also, I have diabetes, sleep apnea and sciatica, so it was a matter of time. I took a new job , because they have BCBS.

Also, you may want to look up the Insurance Commissioner for your state and write to him. .

I agree - contact your State Insurance Commissioner's office Most people don't realize that a lot of what they do if fight for you when it comes to insurance issues. I had a problem years ago with chemo treatments that my insurance refused to cover and which they did cover in the end after I went to the Insurance commissioner's office.

That is insane. However, I have a feeling it will all work out in the end. Honestly, I would contact your local news. WLS has been in the news recently and with all the bad press insurance is getting these days, I bet they would love to do a story.

This is a fantastic idea! Their mistake, you shouldn't be responsible.

I'm self pay, all I am paying is $14000. Which is for surgeon, anthestologist, and hospital. The price you're being told you have to pay is crazy!