This is a very unfortunate situation, however, I would like to make a little clarification on behalf of the office.  My surgery was 6 years ago and insurance was much easier to get approvals for those of us that were overweight and had medical issues.  As time has gone on you'd think the process would become easier... but on the contrary.... Insurance doesn't seem to care what is GOOD for the patient... it's all based on trying to put up hoops and make the patients go away from the surgery so Insurance doesn't have to pay. 

I am sorry you had this experience, but in defense of the office, UHC and Oxford for over a year have been aware that the docs were not going to remain in Network if the Insurance did not agree to pay then on a better scale.  Doctor's are required to notify the Insurance 60 days before end of contract if they are not going to continue.  These docs were told last year that Oxford would begin paying on a scale equal to other Insurance companies, but never came through with a contract to do so. 

the Office went back to UHC/Oxford FOUR MONTHS in advance of their contract renewal to advise if they did not come to a new agreement they would not stay In Network.  The Insurance company by law must notify patients in writing 30 days prior to a doctor going out of network.  The Insurance Company FAILED TO DO THIS.  IN ADDITION, when Doctor's office spoke to Insurance Rep. about this UHC told the Office they WERE NOT to notify the Patients, as that is the requirement of the INSURANCE COMPANY. 

So as much as I do feel for the patients, I see the frustration on BOTH SIDES.  UHC/Oxford has ADMITTED that they have made the ERROR by Failing to Notify their patients.  Their SUGGESTION TO RECTIFY this situation was ... to make things RIGHT... The DOCTORS go ahead and see all their patients for next 60 Days while UHC/Oxford can get their paperwork together and notify patients as law requires.  HOWEVER, this SUGGESTION Did NOT Pay the doctors ANYMORE for their procedures.  So The Insurance just Expect the DOCTOR to Continue to take the bullets for the Insurance Companies error. 

Had the Insurance Company said to the Doctors.... We made the mistake but would like you to continue to see our patients until we can NOTIFY THEM... and We Will PAY you at our OUT OF NETWORK RATE DURING THAT TIME... I'm sure the doctors would have agreed to do so as this would have given a compromise to all parties involved. 

BUT FOR THE INSURANCE TO ADMIT TO THE WRONG DOING WHICH PUT THE CARE OF MANY PATIENTS IN FLUX AND TAKE NO FINACIAL RESPONSIBILITY.... ACTUALLY ASK THE DOCTORS TO SHOULDER THAT BURDEN IS REDICULOUS! 

The Insurance FOR the PAST YEAR Has Strung the Doctor's along thinking they would come back with a Contract for Nov 2010 that would be more competitive rates.  In Good Faith doctors stayed IN Network for an additional year.  UHC/Oxford was well aware that they would be expecting an increase and when they did not offer a competitive contract the doctors were forced to Leave the Network. 

So... in the end I do feel bad for patients that were affected by UHC/Oxfords mistakes.  And If they were MY INSURANCE PROVIDER I would be putting in a complaint with the Division of Banking and Insurance with the STATE.  I am sorry that patients were inconvienced by all this.  The doctor's have not and will not turn away patients, but the office is out of network and patients charges will be processed to their  OUT OF NETWORK Benefits.  So Patients will still be seen, but if you are covered by UHC or Oxford call your member benefits to check what your Out OF Network Benefits are. 

Sometimes we forget as patients that it is our responsability NOT the Doctor's Office to know what are benefits are.  Member Services on the back of your card is where you call to find out.

Dr. Bertha's group has Insurance People who do verify benefits prior to procedures, this they do as a courtesy but ultimately it is the patients responsibility to understand their Insurance benefits.  No One should go to the Hosp. for a procedure without having confirmed with member benefits if it is covered. 

There must be more to the story ...UHC has been known to drag their feet on approvals... I can only imagine how slow they are with contract negotiations for their providers.  I would bet that this situation resulted from red tape created by UHC.

IF UHC approved the procedure and now your surgeon is out of network, I would think UHC IS OBLIGATED to help you find another provider that is in network given the fact that they approved the surgery.

Good luck as  you continue your journey.

 

I'm amid the appeal process for a revision (specificall Band Over ByPass).......can anyone recommend an attorney who can help with this sort appeal?  We're in the Pocono's of PA... surgeon in NJ.

This is great news- congrats!  I just got scheduled for 12-21!  Congrats to both of them and thank you for your help and encouragement!

   letter I used (adapted from nans) I also attached copies of the phyicians notes I referenced etc   RE:      Maria DOB: 10/09   Employer Name:  Employer Acct No: Group Number:               To Whom It May Concern:   I am writing this letter to appeal your decision for denying my medically needed weight loss surgery. My height is 5’4" and my weight is 355 lbs. I have a BMI of 60. As my diet history shows, diet and exercise have helped, but as long term permanent weight loss I feel that weight loss surgery is my only solution. I have researched and learned about weight loss surgery and have worked with my physician and dietician to decide which is the best solution for me. I know there are risks involved with the surgery, but I believe that the risks of being morbidly obese outweigh the risks of surgery.   I am 38 years old and have been overweight since I was about 8 years old. I have been on diets my entire life, having some successes, but would always gain the weight I had lost back, plus more! I will list the diets I have been on throughout my life.   ·                                 Weigh****chers ·                                 Quick Weight Loss ·                                 Physicians Weight Loss ·                                 Diet Center ·                                 Jenny Craig ·                                 Cabbage soup diet ·                                 Mayo Clinic Diet ·                                 Phentermine, under a medical doctor’s care ·                                 Slim Fast ·                                 Bally’s Fitness Center ·                                 Protein Power ·                                 6 Week Body Make-over Diet ·                                 Weigh Down Workshop ·                                 First Place for Health System ·                                 Herbalife Herbal Supplement ·                                 Dexitrim ·                                 Lemonade Cleansing Diet       Currently, I am being monitored by my doctor, being weighed in once a month. I am also seeing a dietician, and working on exercises that I can do with my bad knees such as light yoga and water waling at both The Park Forest Aqua Center and LA Fitness. I began seeing my physician on March 24, 2010 in order to meet the requirements of Aetna’s 6 month physician monitored weight loss program. In addition to my doctor, I saw their in house dietician and am working with a LCSW to address behavior modification issues. I have also joined various local support groups in order to supplement my weight loss journey.   Along with my BMI being 60, I have co-morbid diseases, such as Poly cystic ovarian syndrome (PCOS), sleep apnea, high cholesterol, and pain in my joints, knees and lower legs, GERD as well as lower extremity edema. My family has a history of cancer (mother and father), heart disease (father).  I feel that being morbidly obese puts a strain on everything that I do and also affects my personal hygiene. I cannot walk very far without becoming out of breath. I have a hard time walking up and down stairs because I am out of breath and it hurts my knees. I have a hard time putting on my socks and shoes. I feel I can not live a normal life because I have a hard time fitting in small seats such as on an airplane, in a movie theater, at the ball park, or in a restaurant. I am embarrassed of what I look like, but more importantly, I fear for my health. I want to be around for my family and I feel that my weight is hurting my health. I lack self confidence and feel I am not functioning to my full potential. I want to be more active and be able to do the things normal sized people do.   If you look at my paperwork submitted, you will see that I have met the requirements for qualifying for weight loss surgery as spelled out in the Clinical Policy Bulletin 0157.  *I have had the presence of severe obesity that has persisted for at least the last 8 years *I am over the age of 18, and I have attempted many, many weight loss regimens in the past without long term success *I have a BMI of 60, along with co-morbidities *Lastly, I have completed the process of the 6 month physician supervised weight loss program.  I did this by visiting my physician, visiting the dietician, seeing an LCSW for behavior modification , all which has been documented in the following paperwork. The duration of this program was a full six months, actually 187 days, or 26 weeks, 5 days.   I know this surgery will be a life saver for me. Please reconsider your decision, as I have met the requirements that you have asked for.   Thank you and I look forward to hearing from you soon.   Sincerely,