Guest guest Posted June 2, 2001 Report Share Posted June 2, 2001 I'm hoping someone can give me some assistance. My PCP is all for the DS surgery, and submitted the request to my insurance which is Lifeguard HMO here in Northern California. I expected them to deny it and today I received the denial. They say they will not cover it because the DS doctor is outside of Lifeguard's network and that I need to see an in network surgeon. But of course, there aren't any in network surgeons who do DS. What should my next step be? Should I just go ahead and appeal? I suspect that the next denial would be because they think the DS is the same as RNY and I should go to one of their RNY doctors. Or...should I try to figure out which insurance companies have paid for DS with the DS Dr I want and hope one of them is one I can switch to next year? I do hate the thought of waiting that long. Has anyone had any luck getting insurance approval for DS outside of their network? Sigh... Margy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 2, 2001 Report Share Posted June 2, 2001 If you need treatment that can't be provided in your network, and the treatment itself isn't excluded, shouldn't your insurance pay? DS Approval Problem >I'm hoping someone can give me some assistance. My PCP is all for the >DS surgery, and submitted the request to my insurance which is >Lifeguard HMO here in Northern California. I expected them to deny it >and today I received the denial. They say they will not cover it >because the DS doctor is outside of Lifeguard's network and that I >need to see an in network surgeon. But of course, there aren't any in >network surgeons who do DS. > >What should my next step be? Should I just go ahead and appeal? I >suspect that the next denial would be because they think the DS is >the same as RNY and I should go to one of their RNY doctors. >Or...should I try to figure out which insurance companies have paid >for DS with the DS Dr I want and hope one of them is one I can switch >to next year? I do hate the thought of waiting that long. > >Has anyone had any luck getting insurance approval for DS outside of >their network? > >Sigh... > >Margy > > > > >---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 2, 2001 Report Share Posted June 2, 2001 I'm in a similar situation. My choice of surgery isn't in-network. I decided to have the lap ds. Open ds is done in-network. My PCP will refer me to the lap surgeon, but I will have to make a case to my insurance company for laparoscopic surgery vs. open. I also have some concerns about the open ds surgeon- like he was trained in Poland and he's not a fellow of the American College of Surgeons. I'm not sure that makes a difference to the insurance co; anyone got any wisdom on that? In any case, I have to woo my insurance company for the surgical consultation first. If they approve that, then they will probably approve the surgery. DS Approval Problem>I'm hoping someone can give me some assistance. My PCP is all for the>DS surgery, and submitted the request to my insurance which is>Lifeguard HMO here in Northern California. I expected them to deny it>and today I received the denial. They say they will not cover it>because the DS doctor is outside of Lifeguard's network and that I>need to see an in network surgeon. But of course, there aren't any in>network surgeons who do DS.>>What should my next step be? Should I just go ahead and appeal? I>suspect that the next denial would be because they think the DS is>the same as RNY and I should go to one of their RNY doctors.>Or...should I try to figure out which insurance companies have paid>for DS with the DS Dr I want and hope one of them is one I can switch>to next year? I do hate the thought of waiting that long.>>Has anyone had any luck getting insurance approval for DS outside of>their network?>>Sigh...>>Margy>>>>>----------------------------------------------------------------------> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 3, 2001 Report Share Posted June 3, 2001 If you have insurance through your work, you need to go to through your benefit coordinator in the Human Resources Dept. Your PCP needs to send a letter of referral to them and if they approve it your insurance company has to honor the referral. That is the best way to get around the out of network clause. Then you get to go to the surgeon that the PCP has referred you to. The surgeon then tries to get the insurance to approve the surgery. The PCP can not get your approval for surgery only the approval for the referral to the surgeon. Looks like you need to start all over. If it is a private insurance, this does not apply. Viau http://www.angelfire.com/on/wannabemagic/WLS.html 3/29/01: 3165/29/01: 267 (-49 lbs)Dr Ren, NYUMC http://www.thinforlife.orgTo join the new group for Dr Ren click on the link belowhttp://groups.yahoo.com/group/NYUMC-thinforlife Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 3, 2001 Report Share Posted June 3, 2001 > If you need treatment that can't be provided in your network, and the > treatment itself isn't excluded, shouldn't your insurance pay? > > Well...that's what I think of course! The insurance company says they will approve surgery for morbid obesity, but they only " believe " in the RNY surgery. They don't acknowledge any difference between the RNY and the DS. Margy Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 4, 2001 Report Share Posted June 4, 2001 Just an idea....have you talked to the in network doctor or gotten any info from them? I've seen stories about some doctors saying that they do DS but really don't. Try to find out exactly what he does...if it isn't the real DS...use that to push the issue!! Good luck. Jerry, Pre-op (waiting on insurance approval)Dr. Booth, MS > >Reply-To: duodenalswitch >To: duodenalswitch > >Subject: Re: DS Approval Problem >Date: Sun, 3 Jun 2001 01:27:28 -0400 > >I'm in a similar situation. My choice of surgery isn't in-network. I >decided to have the lap ds. Open ds is done in-network. My PCP will refer >me to the lap surgeon, but I will have to make a case to my insurance >company for laparoscopic surgery vs. open. I also have some concerns about >the open ds surgeon- like he was trained in Poland and he's not a fellow of >the American College of Surgeons. I'm not sure that makes a difference to >the insurance co; anyone got any wisdom on that? In any case, I have to woo >my insurance company for the surgical consultation first. If they approve >that, then they will probably approve the surgery. > DS Approval Problem > > > >I'm hoping someone can give me some assistance. My PCP is all for the > >DS surgery, and submitted the request to my insurance which is > >Lifeguard HMO here in Northern California. I expected them to deny it > >and today I received the denial. They say they will not cover it > >because the DS doctor is outside of Lifeguard's network and that I > >need to see an in network surgeon. But of course, there aren't any in > >network surgeons who do DS. > > > >What should my next step be? Should I just go ahead and appeal? I > >suspect that the next denial would be because they think the DS is > >the same as RNY and I should go to one of their RNY doctors. > >Or...should I try to figure out which insurance companies have paid > >for DS with the DS Dr I want and hope one of them is one I can switch > >to next year? I do hate the thought of waiting that long. > > > >Has anyone had any luck getting insurance approval for DS outside of > >their network? > > > >Sigh... > > > >Margy > > > > > > > > > >---------------------------------------------------------------------- > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 4, 2001 Report Share Posted June 4, 2001 Well, the in-network guy really does DS, but he uses a 6-inch incision to do it. That doesn't work for me. DS Approval Problem>>> >I'm hoping someone can give me some assistance. My PCP is all for the> >DS surgery, and submitted the request to my insurance which is> >Lifeguard HMO here in Northern California. I expected them to deny it> >and today I received the denial. They say they will not cover it> >because the DS doctor is outside of Lifeguard's network and that I> >need to see an in network surgeon. But of course, there aren't any in> >network surgeons who do DS.> >> >What should my next step be? Should I just go ahead and appeal? I> >suspect that the next denial would be because they think the DS is> >the same as RNY and I should go to one of their RNY doctors.> >Or...should I try to figure out which insurance companies have paid> >for DS with the DS Dr I want and hope one of them is one I can switch> >to next year? I do hate the thought of waiting that long.> >> >Has anyone had any luck getting insurance approval for DS outside of> >their network?> >> >Sigh...> >> >Margy> >> >> >> >> >----------------------------------------------------------------------> > Quote Link to comment Share on other sites More sharing options...
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