question

I’m at the end of my rope. I have Cigna insurance. There is no in network doctor that does gastric bypass. I am 380 w/BMI of 58 %. I have called the insurance company and they approved one visit with a out of network doctor at the in network rate. There is only one doctor that does it in my area is out of network. The closest doctor that is in network is 125 miles away. From what I have gotten from my insurance company is that they would pay for the surgery but will not pay for the hospital because they say that there is a hospital in my network that can do the surgery.  Hello the doctor does not use that hospital. Because of this they are denying this surgery.  Plus one of my many calls I had one person said that they saw no reason for me not to be approved. That is the type of policy that I have. How do I fight this?

hello, i dont think i can be of much help, but "gary" who is at the top of this web page has a web site were you might be able to leave him a message on this, he gives really good advice,,,,I fell bad for you and the trouble you are going through, just hang in there--some things are worth fighting for......if it helps any , i have to travel 127 miles each way to go  get my surgery {i'm not approved yet , i'm on the 6 month diet}   Good luck to you and you are not alone with your frustration.... To find the website to get advic look under the column that says"helpful info" bye

That's ridiculous!I think that whoever told you that the out-of-network hospital won't be covered is wrong. If they will approve the surgeon for the in-network rate, they must also approve the hospital--according to the exact same policy that they used to approve the surgeon. They approved the surgeon because there wasn't a surgeon who does gastric bypass in the network in your area, right? Well, that means there also isn't an in-network hospital in your area that does the surgery. They must approve the hospital at the in-network rate as well for the exact same reason. The ad hoc  process for hospitals is a pretty standard thing for insurance companies. If I were you, I would call them back and state that you would like to appeal their refusal to cover the hospital costs on the basis that they covered the surgeon and on the basis that there isn't a hospital in your area that does this procedure. I would demand that they review their ad hoc policy regarding an approved surgical procedure when there is no in-network hospital. I would demand that it be brought to a supervisor, if necessary. I honestly don't believe that the insurance company would approve the surgeon, but not the hospital; I think whoever you talked to is misinformed about their policies...or they're just giving you the run-around.

The insurance company does this all the time... they are only required to approve out of network when there isnt a contracted Dr/facility in a 25 mile radius. Since there wasnt a surgeon... thats why they approved... since there are innetwork hospitals in the area they do not have to approve to use an OON one based on where the surgeon operates... its a catch 22 but they can do it.

Your option at this point would be to have the surgery at the OON hospital and appeal the bills later. Do you have OON coverage? I know the deductible/coinsurance is higher... it could be worth the additional cost to have the surgery. If you have no OON coverage the hospital may be willing to work with you on a discounted rate since you would be paying OOP and a payment plan as well.  Sadly the insurance company doesnt have to approve you to use an OON hospital when there are inetwork hospitals in the area... even if they the OON surgeon is being covered innetwork and doesnt go to any of your hospitals.

Hi Jane - I hope that you find a resolution to this problem soon.  One thing that hasn't been mentioned on previous posts is your financial obligation if the insurance ends up approving the out of network hospital at in network rates.  The hospital is still out of network and doesn't have to accept the insurance's allowed amount (even if the insurance agreed to pay at in network prices).  You are liable for the difference between the allowed amount and the total amount billed.  Suddenly that 125 miles doesn't sound so bad.  Keep your head up.  it will all work out in the end.