What To Expect From The *peer To Peer* ... Cigna Insurance

[Odee 57]

I am so frustrated with Cigna and with my surgeon's office !!!!!! OK, let me calm down.

What should I expect from the *peer to peer* that Cigna is requesting? This whole process has been so frustrating and upsetting, right now I literally feel like I've been punched in the gut.

Sorry for the dramatics, its just one of those days for me today - not just this but everything is going wrong today.

Can anyone offer any advise on the peer to peer? Also, has anyone had to do a formal appeal and won? My surgeon's office said if the peer to peer doesn't work, I am on my own to file an appeal. Ughhhhhhh!!! I feel like I've been on my own the whole time dealing with Cigna.

Sorry for the venting.

Thanks !

[Odee 57]

No one had to have the "peer to peer" ????

[chitowngirl 884]

I've never had one, but I do work in healthcAre and I am familiar with a peer to peer. I can tell you that your surgeon prob doesn't want to do it. Unless there is some medical documentation that he didn't submit with the request it is pretty pointless. Can I asked why they denied you?

[Odee 57]

I was denied because the letter from my doctor did not clearly state "I was CLEARED for surgery". Totally bogus because my doctor basically said that twenty different ways but Cigna wanted exactly those words. This has happened twice and now they want the peer to peer. The coordinator was very bleak about it. I feel terrible because these are just incidental issues they are getting hung up on and more so, I am frustrated with the surgeon's office for not being on top of the requirements. Very depressing to go this far and get stopped over a technicality and the surgeon's coordinator laugh's it off saying "well you can always appeal, you know how insurance companies are". Maybe I am just being overly sensitive because I'm so far into the process and feel like I've put my heart and soul into it.

[chitowngirl 884]

Well I've seen a lot of denials and hardly ever have I seen a doctor do a peer to peer. Usually if he has a PA he/she would be able to do it. Have you considered getting a new surgeon and having them resubmit the request. I also appealed my denial, and it really didn't get me anywhere. So I totally know how you feel. When it comes to insurance issues most doctors don't care to bother with it.

[Need-a-Sleeve 211]

I was denied because the letter from my doctor did not clearly state "I was CLEARED for surgery". Totally bogus because my doctor basically said that twenty different ways but Cigna wanted exactly those words. This has happened twice and now they want the peer to peer. The coordinator was very bleak about it. I feel terrible because these are just incidental issues they are getting hung up on and more so' date=' I am frustrated with the surgeon's office for not being on top of the requirements. Very depressing to go this far and get stopped over a technicality and the surgeon's coordinator laugh's it off saying "well you can always appeal, you know how insurance companies are". Maybe I am just being overly sensitive because I'm so far into the process and feel like I've put my heart and soul into it.[/quote']

Peer to peer means they are sending your file to another doctor to see if he agrees & would support your surgeon's opinion to do surgery. IF this is the kind of response your surgeon's office has (apathetic) I would wonder how serious & experienced they are. The bariatric surgeons that do a high volume are used to dealing with all insurance companies & the roadblocks they may put up. Don't forget THIS is how your doctor makes his living and most doctor offices I know do battle to get procedures approved.

[Odee 57]

That's why I was so surprised about the letter problem. I've seen posts on here where others have said Cigna is very specific about the wording in the letter. Why wouldn't the office know this and why would they twice submit the letter when it was incomplete.

Thanks ladies for the encouragement. Much needed.

[littlemiss0428 30]

Hi Odee: Im a little late jumping in, but Im in the EXACT situation as you. Im currently in the appeals process.. My surgeons office send over All the paperwork except the medical clearance. That was denied. He then re faxed it again and that was considered the second attempt. I went to primary and got the medical clearance. Its too late now and cigna wants a peer/peer. The office doesnt do peer to peer even though it was the doctors fault, and after I explained that it doesnt need to be with the Dr. So now we are at the appeal process. I can find another Dr, re submit and then that should approve it, but what a hassle! My surgeon is considered one of the best in this area, but the office staff isnt helpful. (sounds like a lot of other surgeons)

[Izuri 428]

It sounds like Cigna is a frustrating insurance company to deal with. Whatever you do, don't give up. If this surgeon's office will not do it, see if you can go through another surgeon and have the claim approved somehow.

On the other side of the topic, I haven't worked through a surgeon's office, but I can tell you that insurance companies are just as difficult for medical facilities to deal with. They give the doctor's office just as many run arounds and inaccurate information as they give the patients they cover. It's all around a load of bs. That's not to say your surgeon's office is not at fault for not being willing to do the review, just keep in mind it's hours on the phone for them and the insurance company usually gives them a lot of crap too. I hope you do get things sorted out. And if they don't get it to go through, try the appeal process. But before you do, get in writing (and copy the person's name who gave it to you) exactly what you need and in what words so that you can make sure that they can't pull a fast one on you again.