being screwed by insurance.....

[kyleebean 209]

Last Friday I was supposed to have a follow up apt. with the nurse practitioner, only to have the program manager call me to cancel it. Obviously prior to my surgery the surgery was submitted for approval and after an appeal it was approved (well, one of them were approved, I have to self pay to have the band removed). However, Humana is stating they have a 25,000 cap per life time for Bariatric care. and they paid the hospital their 25,000. Unfortunately, this 25,000 cap was never communicated to me nor to the program manager who submitted the claim for approval. Needless to say this leaves me with a $130,000 bill. My surgery had complications and I was in the hospital for 4 days. I'm so frustrated. I am going to appeal but I don't think it's going to make a difference. I cannot afford this....Had I known this was the case, I would have opted for different treatment and possibly somewhere else. Anyone else ever experience this?

[Bufflehead 6,358]

This sounds all kind of wrong to me. If I were you I'd be looking to hire a lawyer. It won't be cheap but I think it's worth at least looking in to.

[jujubslim 95]

Did you already have the surgery and lap band removal?

[kyleebean 209]

Yes I had the band removed and was sleeved on 11/27/13.

[Catherine707 253]

Wow, and I thought I had problems with my insurance company, you are in insurance hell! First remain calm.... I know it is hard to do! Second gather everything you have that talks about approvals and limits. Anything in writing from your insurance and your employer (if your insurance is through an employer). Third document every single contact you have had with the insurance company. Sit down NOW and do the best you can to remember every time you talked with them and if you have it who you spoke with. OK that will get "your ducks in a row", and get you ready to do battle!

The next step is dependent on your particular situation. Does your employer provide your insurance? If so contact HR and log a complaint about the insurance company not paying for a pre-authorized surgery. Be nice to the HR people, because they can be very helpful in this problem.

Next figure out what other resources you have available to you. Talk with the hospital about if they were aware of any "lifetime cap on bariatric surgery". Ask if they have had problems having the bills paid by your insurance company. I found people at my doctors office and the hospital were very sympathetic and helpful when I realized that they didn't cause the problem, but were victims of the insurance company too.

Does your state have an insurance commissioner? This was the constant threat I held over the head of my insurance company. If they didn't fix my problems I was going to report them..... it worked to get things moving.

Finally get a big dose of patience! I had my surgery on 5/23/13 and the final bill was paid correctly on 1/22/14! It took them 8 months of me badgering them weekly for the bills to be paid as they should have been originally.

Good luck - you CAN win against the insurance company! I can be done!

[jujubslim 95]

You're best best is to appeal at this point. Go online look up your policy and see if you can find any mention of a cap. If it's a plan offered through your employer discuss it with hr.

Not sure what exactly your situation is but also check with your hospitals financial counseling, they may be able to help you see if you're eligible for Medicaid or charity care. Sometimes if you have an existing medical condition you can get retroactive coverage if you're eligible.

Sorry to hear what you're going through.