Re: Conversation with Dr. Gagner's Insurance Coordinator

[Guest guest]

Hi Aviva

I spoke with Darryl the other day....He made it quite clear to me that Cigna here in NJ and NY are not only not easy to get to cover this surgery but that he had, in his 18 months at the office, had 6 cases of Cigna patients and only 2 were covered and they had pull that you can't imagine and that the vast majority of us don't....I know in my case that he was very to the point....and adamant about it....he told me it would be easier to change my insurance than get Cigna to cover me....

Cindy

[Guest guest]

Just had an interesting conversation with Darryl, Dr. Gagner's insurance

coordinator. He told me that despite the information that is circulating online,

he has not had problems with getting patients covered for BPD/DS when the

application is backed by the surgeon's letter detailing the necessity for the

surgery.

He told me that problems in obtaining approval occur only when the coverage is

with a

group that has specifically excluded this surgery from their policy, and that if

this happens, it is something that generally affects smaller groups, but is

usually not the case with large groups.

He said that he works together with Dr. Gagner and Dr. Quinn to prepare the

letter to the insurance company, detailing the medical necessity for BPD/DS, and

has not had any problems getting coverage from any of the large companies, in

New York or elsewhere. He repeated that the only time there is a problem is if

the company has specifically excluded this from their policy, but usually this

is something that happens - if in fact it does happen - with smaller companies.

He had heard about the various notices appearing on the online boards as far as

across-the-board BC/BS denials for the BPD/DS procedure, and says that as far as

his own experience is concerned it simply is not the case. If I may add a

subjective comment, he sounded really exasperated - he immediately knew what I

was referring to, and asked me if I had heard it in their site's chatroom. He

has heard this from several sources, and he said he has no idea how this

information - misinformation as far as he is concerned - began to circulate.

We had quite a thorough talk and he made his point very clearly. We talked

specifically about BPD/DS. I asked him if it was okay with him if I'd post this

info here, to let others know.

Re Dr. Gagner, he is an " out of network " provider at this time.

FYI. I'd be interested in hearing any comments.

Aviva

[Guest guest]

Aviva,

This is very interesting. Aetna has been denying some patients as

well as BC/BS. I have been trying to figure out if it relates to

wheter an employer self insures or is fully insured.

Small companies tend to be fully insured as they cannot assume the

liability for their employees health. As a result the insurance

company is the one that is actually out of pocket for the costs of

the surgery. Most of these polices have exclusions for weight-loss

surgery. These polices are under the jurisdiction of state law which

may vary.

Large companies tend to be self-insured with an insurance company

acting as a " Third-Party adminstrator (TPA) " . Since the insurance

company is not on the hook for the money, I am guessing they are less

inclined to be picky. These polices are under federal jurisdiction

(EURISA), and I have seen it stated somewhare that federal policies

cannot have a restriction against WLS (though I havn't confirmed

that).

I suspect that Dr. Gagner is referring to this split when he talks

about small groups and large groups.

Has anyone who has been denied the DS while covered by a large group?

As for the list being misinformed: I beg to differ. Those who have

denials in writting feel all to well informed!

With luck I will not be among them.

Hull

> Just had an interesting conversation with Darryl, Dr. Gagner's

insurance

> coordinator. He told me that despite the information that is

circulating online,

> he has not had problems with getting patients covered for BPD/DS

when the

> application is backed by the surgeon's letter detailing the

necessity for the

> surgery.

>

> He told me that problems in obtaining approval occur only when the

coverage is

> with a

> group that has specifically excluded this surgery from their

policy, and that if

> this happens, it is something that generally affects smaller

groups, but is

> usually not the case with large groups.

>

> He said that he works together with Dr. Gagner and Dr. Quinn to

prepare the

> letter to the insurance company, detailing the medical necessity

for BPD/DS, and

> has not had any problems getting coverage from any of the large

companies, in

> New York or elsewhere. He repeated that the only time there is a

problem is if

> the company has specifically excluded this from their policy, but

usually this

> is something that happens - if in fact it does happen - with

smaller companies.

>

> He had heard about the various notices appearing on the online

boards as far as

> across-the-board BC/BS denials for the BPD/DS procedure, and says

that as far as

> his own experience is concerned it simply is not the case. If I may

add a

> subjective comment, he sounded really exasperated - he immediately

knew what I

> was referring to, and asked me if I had heard it in their site's

chatroom. He

> has heard this from several sources, and he said he has no idea how

this

> information - misinformation as far as he is concerned - began to

circulate.

>

> We had quite a thorough talk and he made his point very clearly. We

talked

> specifically about BPD/DS. I asked him if it was okay with him if

I'd post this

> info here, to let others know.

>

> Re Dr. Gagner, he is an " out of network " provider at this time.

>

> FYI. I'd be interested in hearing any comments.

>

> Aviva

[Guest guest]

At 16:58 +0000 7/25/01, chull1@... wrote:

>I suspect that Dr. Gagner is referring to this split when he talks

>about small groups and large groups.

>

>Has anyone who has been denied the DS while covered by a large group?

My insurance is 'administered' by BC/BS of TN. The company my DH

works for is self-insured, and is a fairly large steel mfr.

--stella

[Guest guest]

Hi Cindy:

I apparently am one of these 2 people whom got approved, but I didn't have any pull. This was just approved in June. I was told by Ivonne that I was most likely going to be denied from Cigna, as they weren't having any luck getting them to approve. I was also told by Darryl that he was having a very hard time with them, but finally after it was submitted, I was immediately approved-Thank God. Just because one is approved does not mean that they will pay 100 or even 80 percent, as I found out from my original DS 20 months ago.

Darryl is a great guy whom will really work hard to get it approved. Good luck to you,

Patti

Re: Conversation with Dr. Gagner's Insurance Coordinator

Hi Aviva I spoke with Darryl the other day....He made it quite clear to me that Cigna here in NJ and NY are not only not easy to get to cover this surgery but that he had, in his 18 months at the office, had 6 cases of Cigna patients and only 2 were covered and they had pull that you can't imagine and that the vast majority of us don't....I know in my case that he was very to the point....and adamant about it....he told me it would be easier to change my insurance than get Cigna to cover me.... Cindy ----------------------------------------------------------------------