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

[Guest guest]

> Hi Gobo,

>

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

group with your insurance background.

>

> 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...

>

>> If BOTH insurances are PPO's, it's just up to you to decide

>> which is PRIMARY.

>

Hi Terri;

I cannot think of any way to switch insurance carriers 'out of open

season'. If you marry someone who's covered, you get to join his

coverage; If you divorce or lose your husband to death, you get to

drop him from your coverage; if you get a different job, you get to

sign up with the coverage of your new job; if your husband gets a

different job, you get to be covered by his coverage.

Call Dr. Pomp's office and find out how far in advance they are

setting up appointments? There are some DS surgeons here in

the Northwest who are already setting up appointments in

November simply because they are THAT booked. If Dr. Pomp is

that booked, I would go ahead and set up an appointment for

January and then, be the first in line to switch insurances during

the open enrollment period.

I know this isn't necessarily the answer you want but it will

require the least amount of stress. You won't have to fight Goliath

over getting the medical care you need.

If you want to fight the not-so-good fight, I would get a referral to

GO BACK and see the surgeon. When you meet him

face-to-face, explain to him that you need a report to turn into your

insurance. Doc's with HMO contracts are a bit more cooperative

here than doc's who have no affiliation with your insurance

company.

First ask him if he is in agreement with you that the DS is

indicated for you. If he says 'no', just thank him and move on to

the next issue. If he says, 'yes', that is terrific!

Assuming he says yes, tell him that your insurance company

needs a statment from him stating that he agrees with the

patient that the DS is a better choice.

Then, ask him to make a statement such as, " as far as I am

aware " , or, " I do not know of any other plan surgeons who

perform the DS procedure which the patient and I are in

agreement would be the indicated choice " .

If he spews out health advantages to having surgery, if wouldn't

hurt to add those in the letter. How is your PCP on all this? It

wouldn't hurt to get a similarly worded letter from your PCP. The

importants points are to get as much medical agreement as

possible the the DS is the indicated procedure for you; second to

that would be that neither PCP nor approved surgeon are aware

of another plan surgeon who does the DS.

Actually, it might suffice to just get the surgeon's statement that

he does not do the DS. If your HMO reps have half a brain, they

already KNOW how many surgeons there are. Believe me, if they

try to tell you they can't give out surgeon names again, ask for

their name, write it down, as well as the date and the time. Then,

ask to speak to their supervisor immediately. When you ask for a

rep's name and then follow it by asking for their supervisor's

name, they generally know they have messed up.

Ask him to please send the letter to you personally so that you

may attach it to your appeal. This is important so that you get a

chance to read what he wrote before sending it in.

I hope something I've said is useful. Good luck and let me know

how it goes.

hugs,

gobo

[Guest guest]

> Hi Gobo,

>

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

group with your insurance background.

>

> 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...

>

>> If BOTH insurances are PPO's, it's just up to you to decide

>> which is PRIMARY.

>

Hi Terri;

I cannot think of any way to switch insurance carriers 'out of open

season'. If you marry someone who's covered, you get to join his

coverage; If you divorce or lose your husband to death, you get to

drop him from your coverage; if you get a different job, you get to

sign up with the coverage of your new job; if your husband gets a

different job, you get to be covered by his coverage.

Call Dr. Pomp's office and find out how far in advance they are

setting up appointments? There are some DS surgeons here in

the Northwest who are already setting up appointments in

November simply because they are THAT booked. If Dr. Pomp is

that booked, I would go ahead and set up an appointment for

January and then, be the first in line to switch insurances during

the open enrollment period.

I know this isn't necessarily the answer you want but it will

require the least amount of stress. You won't have to fight Goliath

over getting the medical care you need.

If you want to fight the not-so-good fight, I would get a referral to

GO BACK and see the surgeon. When you meet him

face-to-face, explain to him that you need a report to turn into your

insurance. Doc's with HMO contracts are a bit more cooperative

here than doc's who have no affiliation with your insurance

company.

First ask him if he is in agreement with you that the DS is

indicated for you. If he says 'no', just thank him and move on to

the next issue. If he says, 'yes', that is terrific!

Assuming he says yes, tell him that your insurance company

needs a statment from him stating that he agrees with the

patient that the DS is a better choice.

Then, ask him to make a statement such as, " as far as I am

aware " , or, " I do not know of any other plan surgeons who

perform the DS procedure which the patient and I are in

agreement would be the indicated choice " .

If he spews out health advantages to having surgery, if wouldn't

hurt to add those in the letter. How is your PCP on all this? It

wouldn't hurt to get a similarly worded letter from your PCP. The

importants points are to get as much medical agreement as

possible the the DS is the indicated procedure for you; second to

that would be that neither PCP nor approved surgeon are aware

of another plan surgeon who does the DS.

Actually, it might suffice to just get the surgeon's statement that

he does not do the DS. If your HMO reps have half a brain, they

already KNOW how many surgeons there are. Believe me, if they

try to tell you they can't give out surgeon names again, ask for

their name, write it down, as well as the date and the time. Then,

ask to speak to their supervisor immediately. When you ask for a

rep's name and then follow it by asking for their supervisor's

name, they generally know they have messed up.

Ask him to please send the letter to you personally so that you

may attach it to your appeal. This is important so that you get a

chance to read what he wrote before sending it in.

I hope something I've said is useful. Good luck and let me know

how it goes.

hugs,

gobo