Guest guest Posted July 15, 2003 Report Share Posted July 15, 2003 Well, my surgeon's office called this morning. My insurance company, PACIFICARE, had denied my surgery, which is scheduled for Monday. My doctor's nurse was spitting mad when she called me. She said she's been arguing with them for a week now. They said they were denying me because they won't approve a second by-pass surgery. I get on the phone and call PacifiCare. I spend 30 minutes with the first claims person, trying to explain that my surgery is NOT WLS by-pass surgery. I'm 5'10, 155 lbs, I DON'T NEED TO LOSE WEIGHT, this is to FIX a reflux problem, along with taking my gall bladder out. She just doesn't get it...then she tells me that it was denied because my surgeon hasn't complied with sending them all my test results. I asked what test information they needed. She told me they needed a report on my UTI. UTI??????????? I haven't had a test for UTI. I'VE NEVER HAD A URINARY TRACT INFECTION IN MY LIFE. And furthermore, what the hell does a UTI have to do with reflux???? I asked to speak with someone else. She said that my claim was denied by their medical director. I asked to speak to that person. Oh no. We can't give you that person...so I get a claims supervisor. SAME DAMNED ARGUMENT AGAIN. I explain that I do not need WLS bypass surgery, I'm not asking for by pass surgery, I need a revision SO I QUIT THROWING UP EVERY SINGLE DAY OF MY LIFE. I asked her if I had an ulcer, or stomach cancer, would I be approved? Yes. I asked her if she had all her teeth. She said yes. I said, " Well, I don't. And it's because of the reflux. And my surgeon believes that this surgery is medically necessary. " So, she said she would call my surgeon, and tell him to call the medical director, but they'd still turn it down, because it's already been turned down. The fight is on now...My surgeon still has me scheduled for Monday, but we may have to postpone, because neither of us are willing to back down from PacifiCare. They have the test results from 2 endoscopes, a set of barium x-rays, a colonoscopy, and an ultra sound of my gall bladder, and it all boils down to a stupid surgical code they use. Can you tell I'm mad? Jac Life is not a spectator sport Picture It Digital Designs XXX Farm Paint Horses Mail to: jholdaway@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 OK, Jac, I just went through hell with my insurance company for an obviously medically necessary breast reduction, took it all the way to the external Independent Review Board and was still denied. What you have going on here is far worse. You only have a few days here, so you must go right to the top, and since it's virtually impossible to get to the person at the top of our insurance companies, you MUST call your Congressman. This is what they're there for. Just call and say that you need his or her help immediately and, hopefully, they can make a phone call and pull some strings. This will also let the insurance company know that they're not dealing with a lightweight, and you won't be going away any time soon. Also, if you are financially able, get a lawyer to write a threatening letter, even letting them know that you will be going to the media, if necessary. It was too late for me when I realized that I should have done that in the beginning. Just pull out all the big guns now. You shouldn't have your insurance company making you sick. Good luck, in NJ **************************** > Well, my surgeon's office called this morning. My insurance company, > PACIFICARE, had denied my surgery, which is scheduled for Monday. My > doctor's nurse was spitting mad when she called me. She said she's been arguing with them for a week now. They said they were denying me because they won't approve a second by-pass surgery. I get on the phone and call PacifiCare. I spend 30 minutes with the first claims person, trying to explain that my surgery is NOT WLS by-pass surgery. I'm 5'10, 155 lbs, I DON'T NEED TO LOSE WEIGHT, this is to FIX a reflux problem, along with taking my gall bladder out. She just doesn't get it...then she tells me that it was denied because my surgeon hasn't complied with sending them all my test results. I asked what test information they needed. She told me they needed a report on my UTI. UTI??????????? I haven't had a test for UTI. I'VE > NEVER HAD A URINARY TRACT INFECTION IN MY LIFE. And furthermore, what the hell does a UTI have to do with reflux???? > I asked to speak with someone else. She said that my claim was denied by their medical director. I asked to speak to that person. Oh no. We can't give you that person...so I get a claims supervisor. SAME DAMNED ARGUMENT AGAIN. I explain that I do not need WLS bypass surgery, I'm not asking for by pass surgery, I need a revision SO I QUIT THROWING UP EVERY SINGLE DAY OF MY LIFE. I asked her if I had an ulcer, or stomach cancer, would I be approved? Yes. I asked her if she had all her teeth. She said yes. I said, " Well, I don't. And it's because of the reflux. And my surgeon believes that this surgery is medically necessary. " So, she said she would call my surgeon, and tell him to call the medical director, but they'd still turn it > down, because it's already been turned down. The fight is on now...My surgeon still has me scheduled for Monday, but we may have to postpone, because neither of us are willing to back down from PacifiCare. They have the test results from 2 endoscopes, a set of barium x-rays, a colonoscopy, and an ultra sound of my gall bladder, and it all boils down to a stupid surgical code they use. > Can you tell I'm mad? > Jac > Life is not a spectator sport > Picture It Digital Designs > XXX Farm Paint Horses > Mail to: jholdaway@c... > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 You go get 'em Jac. You deserve to live better then this. Lori Owen - Denton, Texas SRVG 7/16/01 Dr. Ritter/Dr. Bryce 479/335/??? On Tue, 15 Jul 2003 21:44:20 -0500 " Jacque Holdaway " writes: > Well, my surgeon's office called this morning. My insurance company, > PACIFICARE, had denied my surgery, which is scheduled for Monday. > My > doctor's nurse was spitting mad when she called me. She said she's > been > arguing with them for a week now. They said they were denying me > because > they won't approve a second by-pass surgery. I get on the phone and > call > PacifiCare. I spend 30 minutes with the first claims person, trying > to > explain that my surgery is NOT WLS by-pass surgery. I'm 5'10, 155 > lbs, I > DON'T NEED TO LOSE WEIGHT, this is to FIX a reflux problem, along > with > taking my gall bladder out. She just doesn't get it...then she > tells me > that it was denied because my surgeon hasn't complied with sending > them all > my test results. I asked what test information they needed. She told > me they > needed a report on my UTI. UTI??????????? I haven't had a test for > UTI. I'VE > NEVER HAD A URINARY TRACT INFECTION IN MY LIFE. And furthermore, > what the > hell does a UTI have to do with reflux???? > I asked to speak with someone else. She said that my claim was > denied by > their medical director. I asked to speak to that person. Oh no. We > can't > give you that person...so I get a claims supervisor. SAME DAMNED > ARGUMENT > AGAIN. I explain that I do not need WLS bypass surgery, I'm not > asking for > by pass surgery, I need a revision SO I QUIT THROWING UP EVERY > SINGLE DAY OF > MY LIFE. I asked her if I had an ulcer, or stomach cancer, would I > be > approved? Yes. I asked her if she had all her teeth. She said yes. I > said, > " Well, I don't. And it's because of the reflux. And my surgeon > believes that > this surgery is medically necessary. " So, she said she would call > my > surgeon, and tell him to call the medical director, but they'd still > turn it > down, because it's already been turned down. The fight is on > now...My > surgeon still has me scheduled for Monday, but we may have to > postpone, > because neither of us are willing to back down from PacifiCare. They > have > the test results from 2 endoscopes, a set of barium x-rays, a > colonoscopy, > and an ultra sound of my gall bladder, and it all boils down to a > stupid > surgical code they use. > Can you tell I'm mad? > Jac > Life is not a spectator sport > Picture It Digital Designs > XXX Farm Paint Horses > Mail to: jholdaway@... > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 To all who " listened " to me rant yesterday... Well, I got up this morning, STILL MAD. AT 8 am, I was back on the phone with PacifiCare. This time I got a person who was more willing to listen, and a lot more sympathetic. She documented every word I said to her, gave me a reference number regarding our conversation, then sent the information on to the Medical Director, and called my surgeon's office back. My surgeon then called the medical director AGAIN. Obviously, they had not actually READ my reports, and had just based their decision on the coding, even though PacifiCare specifically states in their benefits that WLS IS covered (it that was, in fact, what I needed and was having). I pointed this out this morning, as well. Anyway, my call this morning paid off. Sandy, my surgeon's nurse, called me a little while ago, and I've been APPROVED! Surgery goes on as scheduled on Monday morning at 7 am (I don't look forward to getting up at 3 to leave for the hospital at 4 to check in at 5...but that's a small sacrifice at this point...)Bye-bye, jejeunal loop, bye-bye gall bladder, hello to a better feeling me! Jac Life is not a spectator sport Picture It Digital Designs <http://www.pictureitdigitaldesigns.com> XXX Farm Paint Horses <http://members.cox.net/xxxfarmpaints> Mail to: jholdaway@... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 Jac, WHAT wonderful NEWS! See, you stood up for yourself instead of taking what they said at face value. NOT that YOU would ever do THAT! LOL I don't think I would want to be in the shoes of someone with whom you are truly angry. Can't WAIT for the " new " revised edition of JAC! LOL Debbie in Gig Harbor (170cm medial) ladybostons@... http://www.cafeshops.com/copsstore Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 Jac, that's great news! I just hate insurance companies for what they put us through. They're the real bottom feeders in life. Ugh, don't get me started again. Anyway, I'm just glad you snapped their little necks into submission. in NJ > my surgeon's nurse, called me a little while ago, and I've been APPROVED! > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 Way 2 go, Jac! I can just see that former cop leveling her shootin' stick at PacifiCare! Must'a left skidmarks in their undies. --S At 5:00 PM -0500 7/16/03, Jacque Holdaway wrote: > I've been APPROVED! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 16, 2003 Report Share Posted July 16, 2003 Jac, I am very happy and relieved for you. It pays to be persistant. Good luck with the procedure. I will keep good thoughts for you. Diane --- In Graduate-OSSG , " Jacque Holdaway " Anyway, my call this morning paid off. Sandy, my > surgeon's nurse, called me a little while ago, and I've been APPROVED! > Surgery goes on as scheduled on Monday morning at 7 am (I don't look forward > to getting up at 3 to leave for the hospital at 4 to check in at 5...but > that's a small sacrifice at this point...)Bye-bye, jejeunal loop, bye-bye > gall bladder, hello to a better feeling me! > > Jac > Life is not a spectator sport > Picture It Digital Designs <http://www.pictureitdigitaldesigns.com> > XXX Farm Paint Horses <http://members.cox.net/xxxfarmpaints> > Mail to: jholdaway@c... <mailto:jholdaway@c...> Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.