What you should know if you get DENIED....

[josiek1988 70]

This is information most people are unaware of. If you get an insurance denial, call the insurance company and ask them who is reviewing your case. Most companies don't want you to know that is nothe someone qualified to make that decision. These people get paid to say NO!!! BUT if you call and question them on it, you will almost always get an approval!!!! I work in a specialists office and we see this all the time. NEVER TAKE NO FOR AN ANSWER!!!

Edited March 17, 2016 by josiek1988

[liposuction68 178]

Thank you for that information will use if i get denied again not forseeing that though. thank again alot of people need to hear this or read this especially the one 's who are ready to give up or not that type of fighter..

thank you so much ..

[liposuction68 178]

They got their nerves when you or (my husband) has worked and payed off this insurance for years Motherfuckers! oops i just got in my feelings..

[CowgirlJane 14,261]

My sleeve was covered by insurance which was very helpful!

In my case, the bariatric center handled everything and it was quite smooth.

My insurance assigned a nurse to my case (she consulted via phone). I talked to her 1-2x and once she recognized I had alot of support from my center I felt like she was still available, but not involved. I don't know if she was an advocate but my insurance was approved pretty fast.

They covered wls and I was high BMI with many documented weight loss attempts so fairly slam dunk case.

Anyway - would you advise patients to call and question the denial or ask the surgeons office to be the liason. I felt like it minimized misunderstandings.

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[Sunyinflorida 8]

No one is paid to deny your claims. That is nothing but a myth. Most insurance companies have clinicians, i.e., doctors and nurses, that make up their clinical review units these days, too. Most states require that someone Medically trained make these decisions. The criteria used to make the decisions aren't pulled out of some insurance wizards closet, either. The criteria is based on what the Bariatric surgeons professional society suggested standards are and those used by the profession. SO, if you are being denied, either you just don't meet standard, safe guidelines, or the material provided for the review was not clearly supporting that you do meet it. Find out exactly what they need and make certain it's being provided. If they say they need chart notes, get copies. Don't rely just on a letter from a doctor stating its medically necessary. When you claim repairs on your auto, you show the adjuster your car. Your chart notes are the equivalent to that.

[liposuction68 178]

do you work in an insurance company. the lady above just gave her experience as to what she has witness at her job. Unless you do work for them or own one how do you know its a myth.

just curious. actually alot of people get on and have been denied several times with them having all information requested i dont know this whole thing seems like a game playing with peoples lives. like ive said in many many post over weight people (US) dont just roll off the bed one day and ask for surgery nooooooo we have been through our personal hell with emotional eating binging every single diet that comes out plastic surgery therapy medications ect ect the list goes on so it already aggravates me the questions they ask...like have you tried diet before or excercise or have youbeen to a nutritionist or check off what have you tried this whole crap is bull shytt if i just walked in to an emergency room dehydrated from not being able to keep anything with the band they immediately hook me up give me liquids send for and xray send me 3 different specialist to look at me (for 500 a pop) and give me an unfill or more iv at 300 dollars a bag i see the (this is not a bill statements ) all without asking me did you try to drink Water. how many times a day when was your last piss or sip ect ect insurance pays for it..so all the opinions or suggestions i take to heart i take what i want and leave what doesn't make sense to me. im just saying.

[liposuction68 178]

someone posted that in some states bariatric is a mandatory coverage in some states is this true i haven't looked it up yet.

[2goldengirl 2,076]

This is information most people are unaware of. If you get an insurance denial, call the insurance company and ask them who is reviewing your case. Most companies don't want you to know that is nothe someone qualified to make that decision. These people get paid to say NO!!! BUT if you call and question them on it, you will almost always get an approval!!!! I work in a specialists office and we see this all the time. NEVER TAKE NO FOR AN ANSWER!!!

Actually, any health plan that is NCQA or URAC accredited is required to have any denial or appeal reviewed by a physician or pharmacist (depending on whether the denial is about a pharmacy issue) with an active, unrestricted license to practice in the state where the patient lives. Accreditation standards further require that healthcare decisionmaking be free of any financial incentives to either encourage or discourage care.

Edited March 19, 2016 by 2goldengirl

[2goldengirl 2,076]

i dont know this whole thing seems like a game playing with peoples lives... It already aggravates me the questions they ask...like have you tried diet before or excercise or have youbeen to a nutritionist or check off what have you tried this whole crap is bull shytt

You sound very angry. It is anything but a game, and anything but bullshit. Health plans all have medical policies, not just for bariatric surgery but for many, many other things. They're based on evidence-based, national criteria. Where bariatric surgery differs is that most candidates for bariatric surgery are high surgical risks. No health plan wants to approve an elective surgery without assuring that the person who gets it has a reasonable chance of success. Bariatric surgery is elective surgery. You can expect stringent criteria for any elective surgery. Don't believe me? Look up the criteria for, example, a knee replacement.

And yes, this IS my job. I've worked in the healthcare industry for more than thirty years, and twenty in managed care, ten of those in regulatory and accrediation compliance for a national health plan. For more than five years, it's been part of my job to shepherd individuals through the bariatric surgery process. I know how this works.

[liposuction68 178]

Angry is not the word humiliated that i pay for insurance never ever was i not covered and ppo which is a pretty penny. you know.. im just saying that was my feeling or my opinions i get it itsl like paying for car insurance never have a accident until one day you do do and they drop you or charge you OFF. Its' all a RIP oFF no matter how you slice it. it is not for the people. lol ive worked in insurance before car insurance and it was a small owners insurance company and this was like 25 years ago and i was disgusted at what i saw and had to do its all about money in their pockets nothing else.. lololol.

[josiek1988 70]

Listen, all I can tell you about is true experiences I've had. I work for a Pulmonary specialists office and there have been several times that I have had to call insurance companies to get authorization for a patient's procedure, test or medications. One the authorization is submitted it goes to review. If it gets denied I have to call to provide additional information. I know what the guidelines are and what protocol is. But on several occasions I have asked the reviewer what their speciality is and they are dermatologists, ophthalmologists, nephrologists, etc. I think I have only spoken to a pulmonologist maybe once or twice. Tell me what a dermatologist knows about a bronchoscopy??? That is my point, I don't think it's right to have a case reviewed by someone who is not completely aware of all that it entails. And I can tell you, that anytime I asked the person I was speaking with about their specialty, the tone changed and approvals were quickly achieved.

Not looking to upset anyone or start a debate. I am simply telling you what I know from experience. Take or leave it, it's up to you!

[liposuction68 178]

Hi Josie, And that is exactly what i meant in my answer. not looking for any trouble dont want to start any debate it's your experience and i noted it.

i dont come on this web to fight or get people pissed off i come to learn from others experiences and hopefully i can share something that will help other.

thank you.

[josiek1988 70]

Thanks for the support liposuction68!!!

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[liposuction68 178]

Hi i was looking at your information why are you scheduled for august instead of soon. just curious

[applejenn 173]

I've known people who have been denied a few times and a few who were approved in no time. To me, I think it depends on him many claims they have to review, the mood they're in, and sometimes I think they want to get the person to get frustrated and give up.

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