Gobo/The dreaded denial is official (LONG)

[Guest guest]

Hi Gobo,

Thank you for the suggestions! You are SO VALUABLE to this group

with your insurance background. The fact that you are so willing to

share with us is frosting on the cake (yum!)

> #1 About the 'network' problem. What kind of insurance do you

> have? It sounds like you have an HMO because PPO's usually

> are willing to pay at a lower rate for 'out-of-network' services.

> HMO's, on the other hand are just about cast in stone over the

> " network' boundary.

Yes. Capital District Physicians Health Plan (CDPHP) is an HMO.

Technically, there is no coverage at any level for out-of-network. I

knew it would be a stretch, but was hoping to get them to pay if they

had no one internal performing the DS.

> If they are telling you that you can get the surgery 'in-network',

> they MUST tell you who you should be going to. Tell the

> Customer Service Rep. that if they won't tell you who's

> in-network, how are you supposed to know if the surgeon has a

> contract with your insurance?

>

> Regardless of whether you have an HMO or a PPO, they need to

> be able to tell their members, what doctors are part of the plan.

Yes, I do have a complete listing of their participating doctors.

But how would I go about proving no one offers the DS? (I have

already checked the list on duodenal switch.com and none of the DS

docs are CDPHP participating).

I have already had a consult with one participating surgeon who

confirmed he does not do the DS nor does he know of anyone in the

area (hence, in-plan) who does offer this. I am KICKING myself I did

not get him to jot a note to that effect while I was there. I sent

him a letter a few weeks later when I thought of it, but have not

heard back.

> What company is this? What group are you insured through?

I am iunsured through my employer, FleetBoston Financial. I do have

the option to switch to United Health Care PPO. Aside from having

80% out-of-network benefits, Dr Pomp participates! I just would

rather not wait until January (Open Enrollment) to get the ball

rolling again...

> However, you mentioned that your husband is getting ready to

> change his employment status. This is an excellent time. You

> don't need to justify to anyone why you want to be covered on

> your husband's plan; it's your right as his spouse. In fact, you

can KEEP both insurance coverages. However, HMO's generally

> don't mix well with any other insurance. If BOTH insurances are

> PPO's, it's just up to you to decide which is PRIMARY.

He does not yet have a job with healthcare benefits. With the

economy today he might not have one in the near future, either. He

is doing temp work for the time being. Since he is changing

employment status *TO* a job without benefits is it possible for me

to change my health coverage at my job from one plan to another? I

know this may be a little " blurry " but maybe I can sneak it through?

Gosh, I am will to try *anything* at this point! Are there any other

exceptions to the open enrollment window rule? What if I got

divorced? LOL!

I am practically pulling my hair out trying to get around this little

blockade. Thank you for saving my scalp with your suggestions. If

you think of any creative ideas, let me know!

Terri Hassiak

BMI 60

5/9/01 surgery date CANCELLED due to insurance denial

http://www.obesityhelp.com/morbidobesity/profile.phtml?N=H980366398

email(no spaces): bunsofluff @ hotmail.com