Denied after being approved and devastated

[Panda333 275]

I have to get this off of my chest. I'm not super active posting but have read a lot. Here is my story. I have terrific Aetna insurance. I originally wanted to go to the mayo clinic for my surgery but I found out that AETNA needs a facility to be an institute of Quality (IOQ) So mayo clinic wouldn't take me on. Even though I called Aetna and have a letter saying it doesn't need to be an IOQ. Fast forward I found another surgeon, who is not an IOQ but a Center of excellence. They checked with Aetna and said I was covered and signed me up for their program in April. The past four months i've gone through all the steps, the psychologist, chest xrays , upper GI, Cardiac clearance and radiological stress trest, 3 nutrition appointments and weigh ins 60 miles away. 3 check ins with my PCP for weigh ins... oh and my back was thrown out in the middle of this.

I completed all steps and the advocate states today I was denied because they are not in institute of quality but a center of excellence. What?? We checked on this. Then she starts to give me other hospital names. wait..no......WTF. I'm sort of mad at my surgeons office but also Aetna. They said it doesn't matter what they said in writing, they won't cover me because my doctor is not an IOQ. I'm devastated and frankly wish I would have gone to mexico to begin with. I've already spend more money out of pocket than the surgery would be in mexico. nonsense.

needed to vent

[FluffyChix 17,413]

17 minutes ago, Panda333 said:

I have to get this off of my chest. I'm not super active posting but have read a lot. Here is my story. I have terrific Aetna insurance. I originally wanted to go to the mayo clinic for my surgery but I found out that AETNA needs a facility to be an institute of Quality (IOQ) So mayo clinic wouldn't take me on. Even though I called Aetna and have a letter saying it doesn't need to be an IOQ. Fast forward I found another surgeon, who is not an IOQ but a Center of excellence. They checked with Aetna and said I was covered and signed me up for their program in April. The past four months i've gone through all the steps, the psychologist, chest xrays , upper GI, Cardiac clearance and radiological stress trest, 3 nutrition appointments and weigh ins 60 miles away. 3 check ins with my PCP for weigh ins... oh and my back was thrown out in the middle of this.

I completed all steps and the advocate states today I was denied because they are not in institute of quality but a center of excellence. What?? We checked on this. Then she starts to give me other hospital names. wait..no......WTF. I'm sort of mad at my surgeons office but also Aetna. They said it doesn't matter what they said in writing, they won't cover me because my doctor is not an IOQ. I'm devastated and frankly wish I would have gone to Mexico to begin with. I've already spend more money out of pocket than the surgery would be in mexico. nonsense.

needed to vent

Ok. It is devastating. ((hugs)). So grieve for a few hours, then get on top of it. Find out the offices that your insurance covers that are IOQ. Call their office and schedule an appointment this month (do NOT let 30 days lapse from the date of your last RD appointment), so that the clock keeps ticking in you moving the ball toward the goal line.

Explain to the new doc's office that you have had probs with insurance and your present program not being an IOQ and you don't want to start all over! See if they can help slip you in. Then make sure you get your complete medical records from the bariatric surgeon, the RD, the psych, the sleep study, the EGD and take it to the new doc.

I would think they'd want to fast track you in their office cuz you are Ca-CHING! Ready to give em the money without the 3-6 month hassle of earning it up front.

[Panda333 275]

Thank you....very good suggestions. Just need to process all of this..

[FluffyChix 17,413]

33 minutes ago, Panda333 said:

Thank you....very good suggestions. Just need to process all of this..

In baseball terms, you are a "dying quail". An unexpected gift of an opportunity to "score". A bariatric patient who is ready to fall into their lap and have surgery without a 3-6month "sales time line" to wait for the $$$. Any doc can fit another surgery into their schedule for the month, especially if they are a private insurance situation where they actually get paid. So that makes you "HIGHLY DATEABLE". Most surgeons would fall all over themselves at the opportunity you present to them. So be sure you present and explain it that way to the receptionist/nurse/office manager/bariatric coordinator--whomever you have to jack with to get what you want at the new office! But the important thing to know is that time is valuable and the clock is ticking. I'd personally go pick up your records and take them with you in hands. That way no one can say they got lost.

Edited August 28, 2019 by FluffyChix

[Chardonnay40 153]

2 hours ago, Panda333 said:

I have to get this off of my chest. I'm not super active posting but have read a lot. Here is my story. I have terrific Aetna insurance. I originally wanted to go to the mayo clinic for my surgery but I found out that AETNA needs a facility to be an institute of Quality (IOQ) So mayo clinic wouldn't take me on. Even though I called Aetna and have a letter saying it doesn't need to be an IOQ. Fast forward I found another surgeon, who is not an IOQ but a Center of excellence. They checked with Aetna and said I was covered and signed me up for their program in April. The past four months i've gone through all the steps, the psychologist, chest xrays , upper GI, Cardiac clearance and radiological stress trest, 3 nutrition appointments and weigh ins 60 miles away. 3 check ins with my PCP for weigh ins... oh and my back was thrown out in the middle of this.

I completed all steps and the advocate states today I was denied because they are not in institute of quality but a center of excellence. What?? We checked on this. Then she starts to give me other hospital names. wait..no......WTF. I'm sort of mad at my surgeons office but also Aetna. They said it doesn't matter what they said in writing, they won't cover me because my doctor is not an IOQ. I'm devastated and frankly wish I would have gone to Mexico to begin with. I've already spend more money out of pocket than the surgery would be in mexico. nonsense.

needed to vent

sorry to hear about this. This sucks and is devastating. I cannot imagine going through this process AFTER checking and they deny you. Insurance companies are ass holes!

[GreenTealael 24,954]

Can you transfer all of your records to the surgeon(s) your insurance will approve

Good Luck 💜

[SeattleLady 277]

I understand back and forth with the insurance company. Personally, I am hopeful that my new doctor will take the $50,000 plus of testing I have done since April. I am currently waiting on an answer to this very question.

It doesn't make sense to start over.

Sent from my SAMSUNG-SM-G935A using BariatricPal mobile app

[SeattleLady 277]

In baseball terms, you are a "dying quail". An unexpected gift of an opportunity to "score". A bariatric patient who is ready to fall into their lap and have surgery without a 3-6month "sales time line" to wait for the $$$. Any doc can fit another surgery into their schedule for the month, especially if they are a private insurance situation where they actually get paid. [emoji4] So that makes you "HIGHLY DATEABLE". [emoji3] Most surgeons would fall all over themselves at the opportunity you present to them. So be sure you present and explain it that way to the receptionist/nurse/office manager/bariatric coordinator--whomever you have to jack with to get what you want at the new office! But the important thing to know is that time is valuable and the clock is ticking. I'd personally go pick up your records and take them with you in hands. That way no one can say they got lost.

I love this response.

Sent from my SAMSUNG-SM-G935A using BariatricPal mobile app

[Chattanoogagirl 23]

5 hours ago, Chardonnay40 said:

sorry to hear about this. This sucks and is devastating. I cannot imagine going through this process AFTER checking and they deny you. Insurance companies are ass holes!

Is you deductible paid up on your Aetna? I am with Aetna, but through my husbands insurance with Erlanger here in Chattanooga. By having the deducible paid up helps you get to the front of the line I would think.

[Cheeseburgh 3,078]

There are so many Aetna plans. Aetna underwrites plans for companies and they vary so much. I have Aetna and nothing I experienced would pertain to her situation.

I agree with Fluffy, grab your records and find a surgeon they will accept ASAP.

Best of luck.

[Panda333 275]

1 hour ago, Chattanoogagirl said:

Is you deductible paid up on your Aetna? I am with Aetna, but through my husbands insurance with Erlanger here in Chattanooga. By having the deducible paid up helps you get to the front of the line I would think.

Yes, my deductible is paid up! going to try to appeal but then maybe will take my files as others have suggested. Frustrating because I had bonded with my surgeon, etc.

[Chattanoogagirl 23]

4 hours ago, Panda333 said:

Yes, my deductible is paid up! going to try to appeal but then maybe will take my files as others have suggested. Frustrating because I had bonded with my surgeon, etc.

Best of luck to you, sweetie! Keep me up to date on things.

[catwoman7 10,973]

IOQ must be some new designation (??). This is the first time I've ever heard of it. Back when I had it, a lot of policies required you to go to a Center of Excellence. This new IOQ thing must be stricter (??)

UPDATE: I just googled it (which I should have done in the first place!). Sounds like it might be something specific to Aetna, since every hit I've seen so far mentions Aetna in conjunction with IOQ.

Edited August 28, 2019 by catwoman7

[Nicki100 19]

OMG- I have Aetna too. They sent paperwork to my Bariatric Drs. Office and everything. This red head will really be pissed if they pull that s**t on me. They are the Worst and I can’t stand Aetna already. Thanks for your post!

[Nicki100 19]

Thanks again for your post. I’m at the last leg of the GBS process and my doctor’s hospital is now owned and operated by the mayo Clinic. I, too, have Aetna. I left a message with the surgery coordinator to call me and to see it Aetna accepts everything l. If not, I’m def following the advise from the relpy’s you received, above. Wow!