I've had the surgery, and now...

...my insurance company informed me today that my claim was "ineligible", meaning they're refusing to cover any charge relating to the treatment of obesity.  So after receiving authorization, submitting the letter of medical necessity and receiving approval based on medical necessity, AND having the surgeon's offlice DOUBLE CHECK coverage prior to surgery date, they're now refusing to pay for the surgery.

I think I'd be less upset if they'd said this BEFORE surgery, but now what am I supposed to do?  I know the answer to that question.. FIGHT THIS.  I knew that the minute I saw the word ineligible, and I've already disputed the status and gotten in touch (via voicemail, ffs) with the in-house claims adjuster at the insurance company.  I guess I'm just upset, and nervous.  If I lose my appeal, I'll apparently owe way over what the self-pay cost would have been! (self pay is ~14k with my surgeon, my benefits statement from the insurance said I "may owe" ~26k... I don't think my surgeon would allow that, but I have no idea what the hospital will do if this happens..)

I have my first fill appointment on Tuesday, and I'm EMBARRASSED about this entire situation.  I'm going to go obviously, and definitely calling them on Monday to discuss the situation, but I'm just.. ugh.  Does ANYONE have a similar experience that can talk me down off the ledge?

So sorry to hear about the denial of your claim. I am su re if it was authorized they will pay it......
 
I paid claims years ago (my disclaimer LOL) for a major health insurer and there are several things that could have happened. Most claims are automatically adjudicated, never having a claims person even look at it. Some times the system will automatically deny the claim because bariatric surgery is excluded in most cases or the system didn't read the authorization meaning the dates or codes don't match the claim submitted. Those are just some reasons that the system denied the claim.

Call customer service and speak with a representative, have the authorization letter and the EOB with you when you call. Ask them to resubmit the claim for payment, have a claims specialist look at it or give you the information to appeal. I would demand that a specialist look at it first and feel free to ask for a supervisor if you need to.

Try not to worry about it until you speak with someone and if they deny it once again (I know easier said than done).
 
Worst case scenario if you have to pay you should only have the pay the usual and customary that the provider would have been paid which won't even be close to 26,000......  of course they can do what they want to.

I am sure it can be won during appeal.............and it might not even come to that. You were authorized and they should pay

I am with Malley, too, although I now have a sleeve (his former partner, Hitch**** placed my band--ugh!).  Anyway, don't be embarrassed--they are SO fantastic there, and I know that they will help you with this situation.  They are not going to just push you off or make you deal with this alone.  Also, if you had it at New Hope, I'm sure they will give you the self-pay price.  If you had it done at Menorah, not so sure. 
Good luck,
Jenn

I had it done at Menorah (fab facility) so I'm not sure either.  I'm going to call the office Monday and let them know what's going on.  I have so many friends who know Dr Malley and love his practice, and they've all been reassuring me that they'll be behind me on this.  It's just so frustrating.

I'm not sure why I'm surprised, we're going through the same issue with my moms insurance company on a recent hospitalisation.

I would look up your states Insurance Commissioner at your State Capitol and explaine the situation to their office.  My parents had to do this years ago with my first bypass surgery and after the Commissioner made the phone call my bill got paid.  Donlt give up and be willing to stand up and fight.  Best os luck to you.  Please keep us updated on how it turns out. 

 The good news is the surgery is already done. So letter could be a mistake, or too late on their part to not pay now.

omg, mags!  how frustrating!  i have to deal with insurance compaines everyday for work.  their m.o. is to deny claims and hope that they won't be appealled.  You have to be your own advocate but also enlist the people from the doc's office to assist you.  they also deal with this kind of crap all the time.  try and not be embarrassed!  you are definitely not the only one this happens to.  again talk to the doc's office they will help you. i might even talk to them before you call the insurance co. yourself.

hang in there

Very good news today..

I called the claims adjuster back (she'd left two vms while I was at the vet with dear doggy) and after about 5 minutes of going back and forth about what we'd provided and what we hadn't, and repeatedly telling her that I completed all the authorisation they required and received an authorisation notice from their review board.  FINALLY she found the authorisation notice I received from their independent review board.

So long story short, after she found the notice I received, she apologised for the confusion and told me that she would make sure that this was adjusted, gave me her direct number and said if there were any problems, she would get in touch immediately. :)  I'm so relieved I can't even tell you.

Excellent news!  So glad they were able to work it out for you.