Insurance issues

I posted this on the insurance board also, but thought you guys might be interested in my saga! LOL! I have finished my 4 classes for Sonnanstine and had my psych eval over a month ago; still has not been filed for approval with Humana so I begin my daily calls to Kristine. **************************************** My surgeon's office has not even filed with my insurance yet. My problem is that I am already getting conflicting information from my insurance company and my employer. Since 3-2-2007 I have been told by my insurance company AND my employer that bariatric surgery is NOT excluded. We even discussed where I would need to go & the percent @ which it would be covered. (I work for a hospital and they write their own plan...) Our hospital is a bariatric center of excellence. I was not planning on going there, but I WILL go there if I have to. My employer rep said I can go to the hospital I work at OR the hospital near me. Today I called my insurance to see if anything had been filed yet and was told that it had not. Upon further discussion the lady says it (bariatric surg) is not a covered benefit. This is the FIRST time I have heard this EVER. So she said she would check with her supervisor and call me back. I got a message saying it (bariatric surg) was not a covered benefit. So I called the insurance company back because I think they are wrong. Other nurses in my hospital have had it done. The lady that writes the plan for my hospital told me on 3-29 that it was covered; it is covered @ the hospital I want and it is covered @ 80%. My problem is that I can get NO ONE to send me a copy of my certificate of coverage. I have never received it. Humana says they don't have it since it is an employer written policy (How then would they know what is covered?) My employer always has some excuse; they computers are down, etc... The lady I talked to tonight is going to have the Humana supervisor call me in the am. I have a call out to my employer rep, but have had no call back from her yet. I feel like these people don't even know what is covered, so how on earth am *I* supposed to find out? What can I do when they can not even give me the certificate in writing? (And why would a bariatric center of excellence NOT cover it for their own employees?) Seriously, what am I supposed to do? I am starting to call the surgeon's office daily so it can at least get initially filed so that if I am denied I can appeal, but without the certificate, how do I even know what to appeal? Melanie g.

Damn Melanie that sucks big time. I worried for you when you said Humana but hoped since yours is a policy from/for a hospital that it would be different. Is there a HR office at the hospital you work at that you might visit to plead your case for the certificate? I know my HR wasn't too great to work with until I figured the right questions to ask them. Just remember there are very small lines of print when it comes to exclusions and what is covered. The only reason I got the surgery was because I read the line that said yes it was covered as long as it was medically necessary but we had to have a certain insurance. And that insurance wasn't the Humana plan I had all ready. So I switched when AE happened, that took effect at the first of the year and the rest is history along with the 79 lbs so far.

Hey forgot to add on that I hope you get this figured in a favorable way for you. Keep at it. I would hound your HR for the certificate until you get it. After you know for sure that WLS is approved than open season on the rest for the hounding to get it scheduled. GOOD LUCK!

The HR lady that writes the plans is the one that told me it was covered. I think it is HUMANA that is having issues. Like I posted on the other board, I just want Sonnanstine's office to file it already, so when it is denied I can get a lawyer to work on it instead of just me. But I can't do CRAP until Kristine does HER part.

Hang in there Melanie and don't get discouraged...Dr. Sonnanstine is the best, it's difficult waiting, I know...it took me 6 months to hear something but it was because the insurance kept asking for more and more information. The insurance person at my docs office told me she was waiting for documentation from other places...so it may not be that things are not getting done as much as the "hurry up and wait" the office must deal with. Talk to the office to find out what's going on.. Good luck! Brenda

Hey Melanie. I don't know that I can suggest anything you haven't tried or hasn't been suggested. I'm still pulling for you. BTW, I had a great time meeting your mom and brother, etc, this weekend. They seem like quite a group! I hope the pictures came out alright. ~K.

This is a difficult issue to deal with, but we had the exact same thing happen at this hospital and it turned out the insurance company for the Norton Suburban Hospital employees had the contract loaded into their system wrong. Because of the error, whenever my office or a patient would call the insurance they were told there was an exclusion, which was not true. That was two years ago. Then last year, it was partially corrected and patients/hospital employees were told they had gastric bypass benefits, but not lap-band benefits, which was not true either. The long and short of it is that when a hospital employee came to the office for consultation to have surgery, we knew we had to call to HR department at the hospital to put in a call to the insurance to let them know that it was covered. By know, the glitch has been corrected, but i am sure there are a number of hospital employees that believe they have an exclusion that really don't. The insurance is through Humana as well. If the HR person can't help, it may be worth a call to the bariatric surgery director at the hospital you work for -- I bet they know the correct answer as well as how to navigate the system. I hope this information is useful. David Geller, MD Bariatric Surgeons of Kentuckiana Medical Director of Norton Suburban Hospital Bariatric Surgery Program 4001 Dutchmans Lane, 1E Louisville, KY 40207 (502) 893-7151, fax 893-7020 [email protected]