Partially approved... Insurance is FRUSTRATING!

[Sparkle&Storm 21]

I have Regence BCBS of Oregon. They fought me tooth and nail to get this thing approved. It finally went to a panel yesterday. I called this morning and they said it was “partially” approved.

The sleeve gastrectomy is APPROVED. Thank the gods!!!! Hale-freaking-lujah!

But... the 1-day inpatient stay is DENIED.

Huh?

They said they didn’t feel the surgery was complex enough to warrant an inpatient stay and that they would require a lower level of care, such as outpatient observation. 😜 I’m like, sorry, my surgeon is at a center of excellence and they don’t want me to die. But ok! 😂

Has anyone dealt with this? I called the coordinator at OHSU, but she doesn’t work Fridays and there is no one else who handles scheduling or insurance questions. So frustrating!!! She leaves at 4 every day, too, so it’s been so annoying trying to work with her. But that’s another issue altogether! lol!

My required 6 month weight loss program ended in February, but I’ve been fighting with insurance ever since. It’s been 9 months now and still no surgery date in sight 😖

I’m so over this crap!!! How did you get around the inpatient stay? Or convince insurance the surgery is complex?

[allwet 868]

Most stay 1 day. Some programs 2 days and i have seen a few post from people that went home same night after a very early a.m. surgery. No overnight could see you there as late as 10 p.m. so dont think this means surgery to the parking lot.

good luck and it will be worth the hassles.

[James Marusek 5,244]

I suggest you work this problem through you surgeons office. I ran into a similar glitch. My surgery was approved but my hospital stay was not. It wasn't denied. I just was not approved. In my case the surgery had to take place first in order for the surgeon/hospital to be able to make an estimate of how long the hospital recovery process would take. After surgery, I stayed in the hospital for a couple days and it was covered.

[Frustr8 7,886]

Didn't,i read a poster from Texas that says his surgeon does sleeves as an ambulatory or out-patient procedure? Wasn't too longer ago, if I'm remembering right😊

[ewms 57]

I had surgery in the a.m. and was home in the afternoon. My surgeon is revered as one of the top in the country.
Ohio

Sent from my SM-T580 using BariatricPal mobile app

[Sparkle&Storm 21]

50 minutes ago, James Marusek said:

I suggest you work this problem through you surgeons office. I ran into a similar glitch. My surgery was approved but my hospital stay was not. It wasn't denied. I just was not approved. In my case the surgery had to take place first in order for the surgeon/hospital to be able to make an estimate of how long the hospital recovery process would take. After surgery, I stayed in the hospital for a couple days and it was covered.

Interesting... They sent a copy of the letter to my email, and it definitely says the inpatient stay was denied. I find it crazy that the Dr. on the panel wasn’t even a surgeon (speciality was Internal Medicine) and yet they feel qualified to assess the complexities of this surgery. While, yes, that Dr. is probably great at diagnosing rare diseases, they are not a surgeon... Yet, they state the surgery doesn’t warrant an inpatient stay. Seems to me that my surgeon (who has been performing/teaching these surgeries for ages) would know better than he would, but hey... what do i know, right?

I’m glad to hear it can still work out!

I'll definitely be working with my surgeons office. I just wanted to hear from others who have been through it since I have to wait until Monday and I’m impatient! 😉

[Sparkle&Storm 21]

8 minutes ago, ewms said:

I had surgery in the a.m. and was home in the afternoon. My surgeon is revered as one of the top in the country.
Ohio

Sent from my SM-T580 using BariatricPal mobile app

Wow! Good to know! My surgery center is a 3 hour drive, so I’m not quite sure how to arrange it all, but a nearby hotel may be involved. I guess we shall see!

[ewms 57]

Wow! Good to know! My surgery center is a 3 hour drive, so I’m not quite sure how to arrange it all, but a nearby hotel may be involved. I guess we shall see!

Oh a hotel might be a very good plan. Mine was about a 45 minute drive. I had it on a Thursday and Saturday and Sunday I was at my kids' baseball and soccer games. But that initial day I was just sleeping off the anesthesia and staying ahead of any pain. I was just sleeved 5/3.

[Sleeved36 356]

I was sleeved 5/9 at OHSU. Definately work through the surgeon's office. I had a few glitches along the way and they really helped me. The office workers are really good patient advocates. The surgeon and office team are on your side.

Send them a mychart message this weekend so they can get working on it or get back to you faster. Mychart makes it easy to communicate.

Don't worry, it will work out.

[Sparkle&Storm 21]

5 minutes ago, Sleeved36 said:

I was sleeved 5/9 at OHSU. Definately work through the surgeon's office. I had a few glitches along the way and they really helped me. The office workers are really good patient advocates. The surgeon and office team are on your side.

Send them a mychart message this weekend so they can get working on it or get back to you faster. Mychart makes it easy to communicate.

Don't worry, it will work out.

Really? That’s so surprising to hear. I’m glad it was great for you, but my experience at OHSU has been less than stellar. I’ve had to basically hold the coordinators hand throughout this entire process, constantly reminding her to do things that she’s forgotten. Repeating myself over and over and it doesn’t seem to sink in. It was like she wasn’t listening to me, ever. I had to tell her at least a dozen times that my records from my primary doc could be easily accessed electronically as they were linked with OHSU.

Plus, she would say she was going to submit something on a Thursday, then wait a week and a half to actually do it (and only then after I sent a mychart message). I feel like this process would’ve been much smoother with a different coordinator. She made me do so much on my own and refused to ever call my insurance herself. It’s felt like the blind leading the blind! 😆

On the plus side, I absolutely loved Dr. Husain once I finally met her. So having a fantastic surgeon with awesome bedside manner is a major advantage. I know it’ll be worth all the frustrations in the end! 🤷🏼‍♀️