Do NOT take NO for an answer from insurance!

[SqueakyWheel&Ethyl 160]

My insurance company said "No, we don't cover weight loss surgery and tried to hang up the call, but I didn't let them. I pushed and pushed and documented EVERY call, email, fax, etc. two months into this phone battle, they said they have no record I had ever called asking about this procedure. When I sent them my "notes" (date, time, name of contact, discussion points, action points, etc), they saw I wasn't messing around and suddenly became very cooperative. They approved my surgery after a six-month stall of Nutritional Counseling. I hated the delay at first, but now, I'm so glad I did it. It gave me the time I needed to TRULY make peace with his drastic life change. I had my surgery April 17, 2013.

So DO NOT GIVE UP if doors are shut in your face. They might say 'no' but ethically, should say 'yes.' And, you won't know until you exhaust every single what if scenario.

What if I have Diabetes?

What if I've tried and failed other programs?

What if I have other medical issues that would improve with significant weight loss?

What if I'm willing to do six-months of monthly Nutritional Counseling?

What if I'm willing to do a psych evaluation?

I was lucky enough to have dual insurance coverage. My husbands insurance approved it quickly without flinching. My insurance company was cornered because I PLAYED their game by THEIR rules!

Don't ever give up!

[LizC 48]

Thank you for posting this, it really is a huge encouragement. I am still awaiting approval and I most likely will get it due to my high BMI, but I am still super paranoid about getting denied! Thoughts have constantly been running through my mind about what I'm suppose to do if I don't get approved, I wouldn't even know what the next step would be! But this definitely gives me a sense of relief. Thanks again and congrats!

[SqueakyWheel&Ethyl 160]

NEVER NEVER NEVER let anyone with your insurance company sense that you think denial is even an option to consider. If they DONT APPROVE, you call the insurance company and ask for the Medical Director in charge of your procedure approval. You'll probably get a nurse who works with the MD. Ask them what is needed to get this through. Present it like, "I understand your rules for approval are 1. xxxx. I did that. 2. xxx. I did that too. ..." Confirm they see the docs to support each line item. Find out EXACTLY what is missing and tell them you'll make sure it is in their hands by xxxx date.

When you are playing by THEIR RULES and you meet each task as required, they HAVE to approve. Keep that in mind with every contact you make with them.

And, try to keep it in a business tone, non-emotional. If they sense that you already KNOW you are going to get the approval, they know you aren't messing around, you'll be surprised how quickly you'll get your approval just to get you off their backs.

[Need-a-Sleeve 211]

NEVER NEVER NEVER let anyone with your insurance company sense that you think denial is even an option to consider. If they DONT APPROVE' date=' you call the insurance company and ask for the Medical Director in charge of your procedure approval. You'll probably get a nurse who works with the MD. Ask them what is needed to get this through. Present it like, "I understand your rules for approval are 1. xxxx. I did that. 2. xxx. I did that too. ..." Confirm they see the docs to support each line item. Find out EXACTLY what is missing and tell them you'll make sure it is in their hands by xxxx date.

When you are playing by THEIR RULES and you meet each task as required, they HAVE to approve. Keep that in mind with every contact you make with them.

And, try to keep it in a business tone, non-emotional. If they sense that you already KNOW you are going to get the approval, they know you aren't messing around, you'll be surprised how quickly you'll get your approval just to get you off their backs.

[/quote']

I have to comment on this. You are incorrect. Not ALL insurance plans are the same & they absolutely, positively do NOT have to approve you. I am a senior manager in one of the largest health plans in the U.S. & can tell you that some plans absolutely exclude any type of weight loss surgery for any reason--no exceptions. Do I agree with that? Absolutely not, but too often people look upon medical insurance as a right & even in 2014 with healthcare reform a reality, an employer group can STILL deny weight loss surgery coverage. Those are the facts. The fact that you were tenacious & got yours approved is wonderful but it is not the norm for policies that exclude the benefit. Sorry....

[SqueakyWheel&Ethyl 160]

I'm not saying they ALL have to approve you. On the first call I made, mine said they don't cover it. Case closed. But when I pressed further, it turns out they DO cover it if:

1. 100+ lbs. overweight, OR

2. Less than 100 lbs. overweight, but have at least two medical conditions that will be improved or eliminated (in my case, Diabetes and PBC/NASH).

If they had said it doesn't matter how sick you are or how heavy you are, we NEVER cover it, then, I would completely agree with you.

Once they admit they DO cover it under certain circumstances, and the patient meets the criteria, AND the patient fulfills all the terms according to don't you - in your profession - believe they SHOULD honor the terms THEY set?

[SqueakyWheel&Ethyl 160]

Not trying to argue this.... I totally agree, if they absolutely do NOT cover under any circumstances then its done.

My advice is based on the insurance companies that do cover SOME cases, but don't want their customers to know it. Which is pretty common from what I've learned from my own research and my surgeon's insurance specialist.

I think it's unethical to say "no" when asked, when they are aware that SOME cases would be approved under THEIR guidelines.

[Need-a-Sleeve 211]

I'm not saying they ALL have to approve you. On the first call I made' date=' mine said they don't cover it. Case closed. But when I pressed further, it turns out they DO cover it if:

1. 100+ lbs. overweight, OR

2. Less than 100 lbs. overweight, but have at least two medical conditions that will be improved or eliminated (in my case, Diabetes and PBC/NASH).

If they had said it doesn't matter how sick you are or how heavy you are, we NEVER cover it, then, I would completely agree with you.

Once they admit they DO cover it under certain circumstances, and the patient meets the criteria, AND the patient fulfills all the terms according to don't you - in your profession - believe they SHOULD honor the terms THEY set?[/quote']

Yes & that is where your advice is very relevant. If the benefit is covered in the plan & they deny or "stall", the member can always file a formal complaint with their State's Department of Insurance.

I have found the biggest gap is in each member / patient not knowing their policy coverage. Here I am in the business & I would go and ask my nurses if they knew what (if any) limit we had on our own home health coverage. 95% of them did not have a clue--until they needed it!