Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Joni: What type of insurance do you have? Christy California Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Joni, One 'no' does not a decision make! Fight them. Your BMI is 62. What is it they don't get? Do you have to leave this earth before they get it????? Fight, girl! We're behind you 110%. Is it that they are not going to approve any WLS, or is the problem this particular procedure? Will they cover another one? What, exactly, is their reason for refusal? Make them tell you their reasoning. Then you know what you're dealing with. Get a lawyer to go to bat for you. BMI of 62=medical necessity. DUH> What are they, stupid or something? Phillyjude. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Oh the lawyer will have fun with that. . .minority (female) discrimination. No problem. They'll pay. They can't refuse to do for one what they did for another, can they? Where is the logic, especially given your history. Show them the zillion posts of post-ops and the way their comorbidities have disappeared! Show them that you'll be saving them hundreds of thousands of dollars. Did they cahnge this policy after you were covered? Did they announce the changes, notify you, can they prove that? What, they found out that others of their insureds could read? You have a medical necessity by anyone's reasonable standards. . .lots of sources are on the site, and they can't arbitrarily decide to disallow a life-saving procedure just cause you are not dying today. You must fight. For the young people behind us who are going to need this in 10 years. Enough already. They have enough profits, 4 million dollar salaries for thier CEO, check them out. Hit them with dollar figures and their profits; hit them with discrimination. Hit em, hit em, hit em. Know anybody at the NY Times or the Post???? Hang in there. I hear a lawyer calling. . . PhillyJude OOOH They make me ssssooooooooooo mad. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Christy.. I have Blue Cross/Blue Shield (PCP plan) of North Carolina. Joni PLegal4U@... wrote: > Joni: > > What type of insurance do you have? > > Christy > California > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Phyllis... I have Blue Cross/Blue Shield (PCP plan) in North Carolina. Joni mpowell6@... wrote: > Joni, I think we all should post the name of our insurance company and > let everyone know who they are so we can avoid them. Some insurances > just try to get out of paying. I think they feel we will give up and > their stock can go up some more. Phyllis in Fla. > > Joni Shelton wrote: > > > Well everyone... > > It's official. I have been denied for the surgery with Dr. Rutledge. > > Now I have to start this fight again. They said there wasn't enough > > " documentation to make a medical necessity determination " . Don't ya > > just love those guys??? ARGH!!!!!!! If anyone has any appeals > > suggestions, please let me know. > > > > Thanks > > Joni > > BMI 62 > > 380/373/370/362 > > First Insurance Denial 9/25/00 > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 PhillyJude, I plan on fighting...what I don't understand is a fellow County Employee had the surgery about 2-3 months ago..and they approved him no problem....then they all of a sudden changed their guidlines....SUCKS! But I'm going to call them tomorrow and find out exactly what I need to do. Thanks for the support. Joni Judyh1022@... wrote: > Joni, > > One 'no' does not a decision make! Fight them. Your BMI is 62. What is > it they don't get? Do you have to leave this earth before they get it????? > Fight, girl! We're behind you 110%. Is it that they are not going to > approve any WLS, or is the problem this particular procedure? Will they cover > another one? What, exactly, is their reason for refusal? Make them tell > you their reasoning. Then you know what you're dealing with. Get a lawyer to > go to bat for you. BMI of 62=medical necessity. > DUH> What are they, stupid or something? Phillyjude. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Hi, I felt the need to respond to the insurance denial woes so many of you have been having. I dont get to post much since I had my surgery on May 24, but I do try and read most when I get a free moment. I too was in an insurance nightmare. I have Prudential. I was denied 2 times and everytime I disputed their reason they came up with a new one. I finally had a level 2 appeal where I went to meet with their deciding medical staff and their attorney. Dr R had said he would be their via telephone but unfortunately never answered the page. I had sent them all my info and anything I could find on the net about WLS (it total over 100 pages)Ask to send it before hand so they could read it. I was finally approved. Please dont give up. If you can get a letter from your PCP stating he supports your decision, I think that would help. Good luck Jen 5/24/00 down 63 lbs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 Joni, I think we all should post the name of our insurance company and let everyone know who they are so we can avoid them. Some insurances just try to get out of paying. I think they feel we will give up and their stock can go up some more. Phyllis in Fla. Joni Shelton wrote: > Well everyone... > It's official. I have been denied for the surgery with Dr. Rutledge. > Now I have to start this fight again. They said there wasn't enough > " documentation to make a medical necessity determination " . Don't ya > just love those guys??? ARGH!!!!!!! If anyone has any appeals > suggestions, please let me know. > > Thanks > Joni > BMI 62 > 380/373/370/362 > First Insurance Denial 9/25/00 > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 woooops I can't help there I suggest you call the person who signed the letter and ask for her supervisor. If you donot get any results there go higher. The insurance claims examiners are usually unsure what to pay. She may be somewhat new. Don't get too excited Let her know you are not a dummy and wuill not be pushed around. I have Aetna and was denied on an accident claim once and when they called me and said they did not pay bercause they were waiting for accident information. I told them that I remembered getting the letter but thru it in the trash because I knew the information was on the claim. She said no it wasn't. I thenm said I work in the Emergencfy room and I know it was on the claim because I put it there. She checked and guess what. The claim was paid in 24 hours. Phyllis in Fla. What I am saying is don't let them push around. Joni Shelton wrote: > Phyllis... > > I have Blue Cross/Blue Shield (PCP plan) in North Carolina. > > Joni > > mpowell6@... wrote: > > > Joni, I think we all should post the name of our insurance company and > > let everyone know who they are so we can avoid them. Some insurances > > just try to get out of paying. I think they feel we will give up and > > their stock can go up some more. Phyllis in Fla. > > > > Joni Shelton wrote: > > > > > Well everyone... > > > It's official. I have been denied for the surgery with Dr. Rutledge. > > > Now I have to start this fight again. They said there wasn't enough > > > " documentation to make a medical necessity determination " . Don't ya > > > just love those guys??? ARGH!!!!!!! If anyone has any appeals > > > suggestions, please let me know. > > > > > > Thanks > > > Joni > > > BMI 62 > > > 380/373/370/362 > > > First Insurance Denial 9/25/00 > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 I got an approval from Aetna HMO exactly like you just described. Basically, my PCP did it all for me!! He sent 100 pages of information. He wrote a letter, I faxed him a copy of Dr. R's letter and made up a notebook including the patient manual and a whole lot of other things from Dr. R's website and although they said the first copy was lost (yeah, I bet!), we sent another 100 page packet and within a couple of weeks I had my approval. The moral of this story is SEND THEM ANYTHING YOU THINK THEY MAY NEED AND JUST WHEN YOU HAVE SENT THAT..... SEND MORE!!!!!! Good Luck and God Bless!! Garrison ville, OK pre-op--waiting for Dr. R.'s approval of my packet 327 BMI 54 Re: Insurance Denial > Hi, > I felt the need to respond to the insurance denial woes so many of > you have been having. I dont get to post much since I had my surgery > on May 24, but I do try and read most when I get a free moment. I too > was in an insurance nightmare. I have Prudential. I was denied 2 > times and everytime I disputed their reason they came up with a new > one. I finally had a level 2 appeal where I went to meet with their > deciding medical staff and their attorney. Dr R had said he would be > their via telephone but unfortunately never answered the page. I had > sent them all my info and anything I could find on the net about WLS > (it total over 100 pages)Ask to send it before hand so they could > read it. I was finally approved. Please dont give up. If you can get > a letter from your PCP stating he supports your decision, I think > that would help. > Good luck > Jen > 5/24/00 > down 63 lbs > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 Hey , I'm waiting for an appointment, getting my packet together to send to Dr. R's I'm a self-pay and I hope that makes things go more quickly. My bmi is 61, yours is the closest to that, must mean you're pretty short too, LOL. Trudy Strong Re: Insurance Denial > Hi, > I felt the need to respond to the insurance denial woes so many of > you have been having. I dont get to post much since I had my surgery > on May 24, but I do try and read most when I get a free moment. I too > was in an insurance nightmare. I have Prudential. I was denied 2 > times and everytime I disputed their reason they came up with a new > one. I finally had a level 2 appeal where I went to meet with their > deciding medical staff and their attorney. Dr R had said he would be > their via telephone but unfortunately never answered the page. I had > sent them all my info and anything I could find on the net about WLS > (it total over 100 pages)Ask to send it before hand so they could > read it. I was finally approved. Please dont give up. If you can get > a letter from your PCP stating he supports your decision, I think > that would help. > Good luck > Jen > 5/24/00 > down 63 lbs > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 Hi Trudy- I have been surfing this site for a few weeks since my sister, Beaman, had her MGB on 9/6/00. I REALLY looked at myself in the mirror yesterday and realized I have no other choice but to have the surgery. I may have to self pay...How does that work? Installments? Prepay? I really want to know so I can get started. Regina in Charlotte Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 Hi Trudy- Sure I know in Vegas, I've spoken with him a couple to times. I'll do that, I'll contact him. Since we both are just beginning this, maybe we can sort of keep in touch...I'll be looking for your postings. Thanks for the info, Regina in Charlotte Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 Hey Regina... I have no idea how it works, I just started this procedure myself but from LasVegas knows. he's going for surgery on the 4th. Write to him at this site, Okay maybe he can explain things, I'll ease drop on whatever he tells you..LOL good luck! Trudy Re: Re: Insurance Denial Hi Trudy- I have been surfing this site for a few weeks since my sister, Beaman, had her MGB on 9/6/00. I REALLY looked at myself in the mirror yesterday and realized I have no other choice but to have the surgery. I may have to self pay...How does that work? Installments? Prepay? I really want to know so I can get started. Regina in Charlotte Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 Hi Trudy, Im 52 also and trying to get my insurance approval, now they say I need a nutritional consult to make sure I understand the proper nutrition pre and post op, then a psychiatric evaluation. Gee what will they think of next. Pat Nevada pre op Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 29, 2000 Report Share Posted September 29, 2000 Regina, I had the exact same thought, it sure will help me to have someone right beside me going thru the very same thing.. How old are you, I'm 52, (birthday 53 on the 3rd) Married with five kids, and a husband 12 yrs younger than me.. ugh, thats why it is so important for me to be able to keep up!! Love to share with you, Trudy Re: Re: Insurance Denial Hi Trudy- Sure I know in Vegas, I've spoken with him a couple to times. I'll do that, I'll contact him. Since we both are just beginning this, maybe we can sort of keep in touch...I'll be looking for your postings. Thanks for the info, Regina in Charlotte Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 30, 2000 Report Share Posted September 30, 2000 Thanks, Beth............. Regina in Charlotte Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 30, 2000 Report Share Posted September 30, 2000 Hi Regina, I just had my MGB self pay on August 10th. I had to pay all the money up front. I took out a home equity loan. Since then, though I have seen posts about a company that loans out money for medical procedures. in Las Vegas knows more about this. Anyway, here is how my cost came out. Dr. Rutledge $3455, Durham Regional $11,000 deposit, total bill coming to $6005. (have not seen the refund check yet) Anesthesiologist $926. We stayed at the Extended Stay America hotel. $37.50 per night. Clean with a refrigerator, stove, microwave, the wonderful recliner and a data port. They have a website that gives you all the info at: http://www.extendedstay.com/ You can even see the rooms. As for medications, even though my insurance did not pay for the MGB, it paid for all my pre-op and post-op meds. I only had to pay my co- pay. However, another tip to save us self pays some money is to go to your PCP for any samples they can give you! I know, had I not gotten the antibiotic pill from my PCP, it would have cost me $15.85 for ONE PILL! My PCP also gave me a month's supply of Prevacid. So it pays to give that a try. Hope this helped! Good Luck. Beth in Florida Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 30, 2000 Report Share Posted September 30, 2000 Yes Trudy, I am 5'3 " . There aren't a whole lot of people much shorter than me. I'm glad you wrote a few words. I am waiting on an approval from Dr. R. Hopefully, it won't be a whole lot longer before I hear something. I overnighted it on Wednesday morning. According to Airborne Express, it was delivered Thursday morning so I hope to hear something by Thursday at the latest as I was told by his office it usually takes a week. Good luck in your quest! Re: Insurance Denial > > > > Hi, > > I felt the need to respond to the insurance denial woes so many of > > you have been having. I dont get to post much since I had my surgery > > on May 24, but I do try and read most when I get a free moment. I too > > was in an insurance nightmare. I have Prudential. I was denied 2 > > times and everytime I disputed their reason they came up with a new > > one. I finally had a level 2 appeal where I went to meet with their > > deciding medical staff and their attorney. Dr R had said he would be > > their via telephone but unfortunately never answered the page. I had > > sent them all my info and anything I could find on the net about WLS > > (it total over 100 pages)Ask to send it before hand so they could > > read it. I was finally approved. Please dont give up. If you can get > > a letter from your PCP stating he supports your decision, I think > > that would help. > > Good luck > > Jen > > 5/24/00 > > down 63 lbs > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 1, 2000 Report Share Posted October 1, 2000 Pat, thats why I'm self-paying. The university of chicago hospitals cost for laproscopic RXY was 45,000 dollars, my 40% would have been 18,000 dollars, so this is much cheaper for me. Good luck, Maybe we'll be going together. Trudy Re: Re: Insurance Denial Hi Trudy, Im 52 also and trying to get my insurance approval, now they say I need a nutritional consult to make sure I understand the proper nutrition pre and post op, then a psychiatric evaluation. Gee what will they think of next. Pat Nevada pre op Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 Thanks for the responses... unfortunately, this isn't my company. I am still under my mom's insurance and it would be up to her to have to go bug HR. I'm pretty sure she wouldn't want to do that and make waves with the company, if you know what i mean.... Guess I'll go on living the life of a fat girl.... Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 5, 2001 Report Share Posted November 5, 2001 Is there any reason you can't call her HR directly? That's what I did when I needed help, and no one raised an eyebrow. ALSO, HR *has* to keep medical stuff confidential...in fact, I think they're supposed to keep everything confidential. Keep working on Mom, or maybe start working on a loan for Spain? If you're feeling like I am, " going on living the life of a fat girl " isn't much of an option b/c it's not enough of a life. ~alyssa, pre-op surgery date: 12/20 duodenalswitch wrote: > Thanks for the responses... unfortunately, this isn't my company. I am still under my mom's insurance and it would be up to her to have to go bug HR. I'm pretty sure she wouldn't want to do that and make waves with the company, if you know what i mean.... Guess I'll go on living the life of a fat girl.... Quote Link to comment Share on other sites More sharing options...
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