Re: The dreaded denial is official (LONG)

[Guest guest]

Hi Terri;

Things may not be horrible but you're going to have to be willing

to take the initiative.

#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.

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.

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

#2 There are a couple of ways to change from one group

insurance to another outside the 'Open Enrollment' period. One

is if you join another group and are entitled to insurance through

that other group. Usually, this entails changing jobs. That is

usually an unrealistic plan.

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.

If he will have choices, make sure you look at limitations on

Weight Loss Surgery. Also, you'd be better off with a PPO than

with an HMO. I recommend spending more if you have to, just to

get through the surgery with the surgeon of your choice. Then,

next year, during the Open Enrollment period, you can cut back

with a cheaper plan. This way, you'd just be paying a bit extra for

just one year.

If you have anymore questions, please write me.

Insurance is the one thing I know and have had plenty of

experience with. If I can help, I'm happy to do so.

good luck,

gobo

> Well, I got the call this afternoon. My insurance is denying my

> switch with Dr Pomp because he is out-of-network and they

think it

> *can* be done " in-plan " . I explained to the case manager

yesterday

> that there are no in-plan doctors doing the BPD/DS and she

wanted Dr

> Pomp to write a letter to that effect. Darryl said

> essentially that Dr Pomp was not going to do that (which I do

> understand, I mean how is he supposed to know that no one

in-plan

> does the switch?).

>

> I did ask her if they were so certain it could be done in-plan to

> give me the name of a surgeon who does the BPD/DS.

Strangely they

> are not able to " recommend " physicians. So I was told that to

pursue

> this further I would have to appeal. She suggested I have my

PCP

> write a letter stating the lack of in-plan DS docs. This will

prove

> interesting as my PCP has been a rather reluctant player in my

> journey. Hopefully, I can get an appointment with him soon

and try

> again to win him over.

>

> Has anyone been able to succesfully get out-of-network

coverage for

> the DS because no in-network docs do the DS? What did you

send to

> your insurance to " prove " your case? It seems to me anything

less

> than a sworn statement from every single in-plan surgeon

stating they

> don't perform the DS still leaves the insurance co wiggle room

to

> reject.

>

> I am fortunate that I can switch insurances at the end of the

year to

> one that Dr Pomp participates in. But I really don't want to wait

> that long. As it is, I am afraid I am gaining too much weight

> pre-op.

>

> Has anyone had any luck trying to switch insurances outside of

annual

> enrollment without a formal qualifying change? Or what can I

say is

> a qualifying change that will help my case? My spouses

employment

> status is changing. He is going from full-time student to

working

> full-time without benefits. Can I justify needing to change

health

> plans for this reason? Any other creative ideas?

>

> So, I'm down, but not out. At least my insurance didn't deny me

due

> to the exclusion in my policy or due to DS being experimental. I

> think those would be tougher to fight. Sorry about the length of

my

> post. Just needing to vent a little. I can't say I'm surprised but

> I did allow myself to believe a miracle might actually be

possible.

> And it still hurts.

>

> Thank you for listening.

>

> Terri Hassiak

> BMI 60

>

http://www.obesityhelp.com/morbidobesity/profile.phtml?N=H98

0366398

> May 9th date cancelled due to insurance denial

> email(no spaces): bunsofluff @ hotmail.com

[Guest guest]

--- Terri Hassiak bunsofluff@...> wrote:

She suggested

> I have my PCP

> write a letter stating the lack of in-plan DS docs.

> This will prove

> interesting as my PCP has been a rather reluctant

> player in my

> journey. Hopefully, I can get an appointment with

> him soon and try

> again to win him over.

Boy Terri I sure know the hell of trying to win over

the PCP ! I'm on my 2nd PCP and looks like I'll be

moving on to the third....Best of luck to you !

Sharon in NY

__________________________________________________

[Guest guest]

--- Terri Hassiak bunsofluff@...> wrote:

She suggested

> I have my PCP

> write a letter stating the lack of in-plan DS docs.

> This will prove

> interesting as my PCP has been a rather reluctant

> player in my

> journey. Hopefully, I can get an appointment with

> him soon and try

> again to win him over.

Boy Terri I sure know the hell of trying to win over

the PCP ! I'm on my 2nd PCP and looks like I'll be

moving on to the third....Best of luck to you !

Sharon in NY

__________________________________________________