Insurance Denied Me!!! Please help with any suggestions!!!

Hello,

I have HAP insurance through my husband’s job and I have been trying to get approved for surgery for at least 6 months.  In that time I have gotten three different denial letters for this procedure.  First time it was because I didn’t have enough information for them to review, so I sent them the information they were asking for!  The second time is because they wanted my records from a doctor that I had been seeing in this weight loss program for over a year, I sent them that information!  Now, this third time was because the doctor that I saw for over a year, they said “was not a hospital affiliated doctor."  I don’t know what else to do or where to turn too!!!  Is there anyone out there that can give any advice on what steps to take to get this approved!!  I am in tears writing this letter and need help desperately!!! I will try anything!!!

Thanks,

Carol

You need to appeal, but I'm not exactly sure how that process goes.  Is there an insurance coordinator with the surgeon's office that you can speak to?  I'm sure they deal with appleals frequently and may be able to tell you what steps to take next.  There is also an insurance board on OH that you may get more answers on. 

I have appealed three times!  They keep telling me no!  I will try the insurance board!  Thanks for your advice!

God Bless!
Carol

Insurance companies have rules they usually follow. They many not approve a surgeon you've chosen, and only allow you to use the surgeon that works within their listed doctors.  My Kaiser insurance has Kaiser doctors who perform the RNY procedure, as well as referral to one local surgeon who is a non Kaiser doctor, but has had a 9 year history of LAP RNY surgeries.  You may have to use a surgeon they approve, and not a surgeon you've chosen, if you want your insurance company to pay for surgery. DAVE

Hi Dave,

Thanks for the info, but I have not even been able to get to that stage...I need a pre-approval and they won't give it to me!!! 

Carol

Hello Carol,
First I would go thru your benefit booklet and see what their criteria is for weight loss surgery preapproval. See if they have a medical policy regarding this first. They have something in writing that should state these criterias. When you get it take it to your doctor and talk to them about  that criteria. Make sure they don't require you to use one of their doctors even for the preapproval stage. Also

 Don't give up Carol!  I know how upsetting and frustrating this can be and have been where you are in the past.  There are a lot of good appeal letters floating around here on OH and other WLS sites.  You need to get a good appeal letter going.  

I'm familiar with HAP...and it's a HMO (health maintenance organization), which are known for making people jump through more hoops than a lot of other insurance companies. I also suggest going to a doctor that participates with HAP...perhaps one at any of the Henry Ford Health System facilities.  Bring all those records with you when you go to that appointment and give the office a copy for their records.  Then request the HAP provider to write a letter/referral based on your other records recommending you for WLS (weight loss surgery).  

When you send in your appeal, include the letter from the HAP provider and your own appeal, as well as another copy of any records you have.  The more information you include, the better!  If you have to copy a good one from here that closely matches your needs.  Most people will even say you can use theirs, just edit it as needed.  Make sure you list your co-morbidities, reference any studies that back up your claim and reasons.  

I also suggest searching the archives for appeal letters and denial letters for ideas.

Good luck...and don't give up the fight!  They (HAP) want you to give up, but remember quitters never win!  

~Roxy

I tried for six years. If they require medical supervision from a doctor they approve of ask for a list and go to one of those doctors. Insurance companies set up hurdles for a reason so if you want the procedure to be covered ask them for very explicit instructions. Nothing they've asked for is unusual. Just keep at it and don't take it personally. Susan