Rant/Vent about Insurance

[stacyrg2 350]

This is going to be long, so I apologize. I'm just frustrated. I'm almost 2 years post VSG and have developed a significant case of GERD. It's so severe, and not controlled by medication, that my surgeon feels we can't just let it go. He has recommended that I undergo a procedure called stretta, which seems promising. We submitted for approval to my insurance company which promptly rejected the request (took them all of 3 business days) on the grounds that the procedure is experimental and there are well accepted alternatives, including pharmaceutical therapy and Nissen Fundoplication. Well, I'm not controlled by medication and the only combination that provides any relief Protonix/Dexilant was already rejected by the Company (they won't pay for the Dexilant and at almost $400 a month, the cost is almost prohibitive). Also, given that I no longer have a fundus, a fundoplication isn't available to me (nice going insurance co . . . way to review my medical records). My final option is conversion to bypass, which I really don't want to do. Other than my GERD, I LOVE my sleeve. It's allowed me to lose 130lbs and live an active lifestyle I've only dreamed about. I like having my pyloric valve and not having to worry about dumping, reactive hypoglycemia, etc. Also, the thought of another major surgery is not thrilling me. Anyway, my surgeon gave me the cost for both Stretta ($5,000) and conversion ($100,000). We decided to seek approval for conversion just to have it in our back pocket while we appeal the denial to my state Department of Insurance. Wouldn't you know it, they approved the $100,000 surgery. This is a prime example of what's wrong with the insurance industry. Why would you approve a $100,000 solution to a $5,000 problem???? Just frustrated beyond belief and knew this was a good place to get out my aggression . . . here and in my kickboxing class where I visualize the Ins. co's medical director's face as my target!

[JamieLogical 8,727]

Ugh! It makes no sense! I really really hate insurance companies. I had to self-pay for my VSG because my insurance company would only approve WLS with a documented BMI over 40 for 5 years. Well I had managed to lose 90 pounds on my own about 4 years prior to pursuing VSG and my BMI had JUST crept back up over 40. So they wouldn't approve me for surgery because I had at least TRIED to lose weight on my own? I felt like the were punishing me for trying to do it without surgery. My options were to stay fat for 5 more years or just pay for it myself.

[2goldengirl 2,076]

It isn't about the $$, it's about a proven procedure vs. an experimental one. Your insurance policy probably has a clause that excludes experimental or investigational treatments.

I'm sorry you're upset, really. I hope your appeal comes through.

[stacyrg2 350]

It isn't about the $$, it's about a proven procedure vs. an experimental one. Your insurance policy probably has a clause that excludes experimental or investigational treatments.

I'm sorry you're upset, really. I hope your appeal comes through.

I'm a lawyer practicing insurance law, so get all about exclusions. There is no experimental carve out in my policy. And, at this point, stretta shouldn't be considered experimental as its well accepted in the medical community and has been shown to be a viable fix for GERD for close to 10 years. What bothers me the most is that they insurance company is forcing me into a potentially life-altering procedure when there's an available fix with little to no risk. Penny wise, dollar foolish. I'm planning on paying for the procedure, but will not abandon my appeal with the Department of Insurance because I'm hoping that by appealing, I can do my part to make this procedure more readily available.

[melyssafaye 181]

I'm sorry you're going through this. Insurance can be complicated and make no sense to us mere mortals..

Edited March 21, 2016 by melyssafaye

[2goldengirl 2,076]

Forgive me, but the insurer isn't "forcing" you to do anything - insurance merely says what they will, or won't, pay for.

[stacyrg2 350]

Forgive me, but the insurer isn't "forcing" you to do anything - insurance merely says what they will, or won't, pay for.

And forgive me for my poor choice of words. I'm lucky in that I have options since I have the resources to pay for a procedure that likely will prevent me from developing esophageal cancer, as that's where I'm heading since there is so much stomach acid splashing up damaging my esophagus. But in my view, the insurance company sure as hell is forcing me (or those like me who don't have the financial ability to pay for the procedure) to convert to bypass, and face the potential side effects/surgical risks if I want to "cure" the problem by utilizing the benefits I pay for. Like I said, I'm very fortunate that I can pull out my checkbook and have the procedure tomorrow. But I pay for an insurance policy and I would like the individuals who work for that company to pull their heads out of their assholes and (1) read my medical records; (2) approve medication that offers some relief of my symptoms rather than insist that I try Omeprazole or other lower level PPIs which provide no relief (a fact that is reflected in my medical records); and (3) stop insisting on a medical procedure that I CAN'T HAVE because of my lack of a fundus. I would be more accepting if there was some actual thought behind the denial. So, you're right. The company is not "forcing" me to accept their very generous offer to pay for a conversion to bypass. Except they kinda are, if I want any insurance coverage. They've presented me with the textbook definition of a Hobson's Choice, since they disclaimed liability for any alternative treatments. I pity the poor person who doesn't have the financial means to make decisions regarding their care without relying on insurance coverage. Sorry if my position regarding the workings of insurance companies in the healthcare arena is distasteful to your sensibilities.

[OutsideMatchInside 10,166]

It isn't about the $$, it's about a proven procedure vs. an experimental one. Your insurance policy probably has a clause that excludes experimental or investigational treatments.

I'm sorry you're upset, really. I hope your appeal comes through.

The sleeve was classified as experimental a few years ago, until they realized it was cheaper option with fewer complications than RNY.

[OutsideMatchInside 10,166]

Forgive me, but the insurer isn't "forcing" you to do anything - insurance merely says what they will, or won't, pay for.

And forgive me for my poor choice of words. I'm lucky in that I have options since I have the resources to pay for a procedure that likely will prevent me from developing esophageal cancer, as that's where I'm heading since there is so much stomach acid splashing up damaging my esophagus. But in my view, the insurance company sure as hell is forcing me (or those like me who don't have the financial ability to pay for the procedure) to convert to bypass, and face the potential side effects/surgical risks if I want to "cure" the problem by utilizing the benefits I pay for. Like I said, I'm very fortunate that I can pull out my checkbook and have the procedure tomorrow. But I pay for an insurance policy and I would like the individuals who work for that company to pull their heads out of their assholes and (1) read my medical records; (2) approve medication that offers some relief of my symptoms rather than insist that I try Omeprazole or other lower level PPIs which provide no relief (a fact that is reflected in my medical records); and (3) stop insisting on a medical procedure that I CAN'T HAVE because of my lack of a fundus. I would be more accepting if there was some actual thought behind the denial. So, you're right. The company is not "forcing" me to accept their very generous offer to pay for a conversion to bypass. Except they kinda are, if I want any insurance coverage. They've presented me with the textbook definition of a Hobson's Choice, since they disclaimed liability for any alternative treatments. I pity the poor person who doesn't have the financial means to make decisions regarding their care without relying on insurance coverage. Sorry if my position regarding the workings of insurance companies in the healthcare arena is distasteful to your sensibilities.

A lot people that post here think Drs are Gods also and people should be grateful for whatever Drs what to do for or with them, not realizing they are paid professionals like everyone else.

I work for myself and I am moderately comfortable so I have more options when it comes to healthcare than most people. If you lack financial means, healthcare really sucks.

In your position I would just pay out of pocket for the surgery I want and avoid the gastric bypass.

Good luck.

[Sharon1964 2,530]

As of 2013, stretta was covered by Medicare in 12 states, by Tricare and the VA, and by select other commercial carriers. Medicare doesn't cover experimental procedures, so perhaps you can use that info in your appeal.

http://www.prnewswire.com/news-releases/stretta-procedure-for-gerd-successful-10-year-follow-up-data-presented-at-digestive-disease-week--sustained-improvement-long-term-efficacy-208047551.html

[Valentina 2,642]

My question:

What is your bariatric surgeon willing to do for you???

Is he/she going to insist on a doctor to doctor conference call with your insurance company?

Remember that most of the time an "approval" or a "denial" is already "templated" for whoever receives your request onto their station/desk--usually not a medical doctor of any kind.

Your surgeon can take the easy way out and just accept your self pay offer OR she/he can and should have the facts and figures to stand behind his diagnosis and plan of treatment, then be willing to pick up the phone and "fight" for what he/she thinks is what is in your best interest.

That takes the $ out of the equation and replaces it with what is best for YOU.

If you truly think that a RNY is not for you, than stand firm and fight---being damned sure your surgeon is willing to do the same. Otherwise, in my opinion, you need a different surgeon.

You can always self pay (your words), but here and now, you have the opportunity to do the "right thing". Others following down the same path for years to come will be grateful that you fought the fight not only for yourself, but for them (who probably would not have the privilege of self paying).

"Integrity is doing the right thing when no one is watching"

[stacyrg2 350]

My surgeon is by no means taking the easy way out. My insurance company has a no appeal policy on this procedure. So, while my surgeon has requested a peer to peer review, it has been refused twice. My surgeon is working with me and the legal team from the stretta manufacturer to appeal to my state Dept. of Insurance seeking an independent medical review. My surgeon is behind me 100%. There should be no question in anyone's mind that my surgeon isn't working for me. He's already done more than most when it comes to this fight.

One of the reasons I filed with the Dept of Insurance rather than pay for my procedure and be on my merry way is because I don't believe an insurance company should be able to blanket deny procedures and/or medications without justification. I'm fighting through the Dept. of Insurance so maybe the next person who has this problem will be able to get the treatment they need without the struggle.

Sent from my iPhone using the BariatricPal App

[stacyrg2 350]

As of 2013, stretta was covered by Medicare in 12 states, by Tricare and the VA, and by select other commercial carriers. Medicare doesn't cover experimental procedures, so perhaps you can use that info in your appeal.

http://www.prnewswire.com/news-releases/stretta-procedure-for-gerd-successful-10-year-follow-up-data-presented-at-digestive-disease-week--sustained-improvement-long-term-efficacy-208047551.html

Thank you so much! I have an appointment tomorrow with the VP of reimbursement for the company that manufacturers stretta. They have agreed to partner with me and fight the insurance company through the Dept. of Insurance. This is precisely the type of information I need to present in my appeal

Sent from my iPhone using the BariatricPal App

[mngreeneyes 674]

Good luck on your appeal. I hope it all works out.

pam

[2goldengirl 2,076]

No appeal policy? Wow. What state are you in?