Tips for newbies who are worried about qualifying for insurance (xpost)
It seems I say these same things to many threads on this topic, so I thought I'd put them here. Vets, please feel free to chime in. These are tricks I learned In my 5.5 month appeals fight with my insurance, UHC. When I started, my BMI was 38.3. My insurance required a BMI of 40. I won, eventually. For all of the people here I have talked to, I have only heard from ONE person who has the same criteria I needed to meet. One.
1. First thing: get a copy of your insurance plan requirements in writing so you know exactly what you are up against. If you meet the requirements *in that document*, you will be approved, period. It amazes me the number of folks who have never seen this document. Contact your HR office. They should have it.
2. Get a verified height from your PCP or surgeon at the beginning of the process and use that for your BMI calculations. That is the height you want your insurance to use. Don't cheat, but make sure that you are not attempting to do your best supermodel impression, either. Height is not your friend at this point. I had a variance of 1.5 self reported inches over the years in my various medical records.
3. It is also in your best interest to weigh heavy. Again, I am not suggesting you cheat, but wear thick pants, heavy shoes, etc. that day. You get the idea...
4. Regarding denials: I had 2 of them, plus my first surgeon's insurance coordinator told me there as nothing else she could do for me, which was BS, but that is a different story. I hired an advocate (Walter Lindstrom) to get me through the process because I didn't have time with work to be able to stay on top of it. Can you self advocate and manage your own appeals? Definitely, but the path I took was the right one for me. If you do manage your own appeals, pay VERY CLOSE attention to dates and back up your assertions with facts from your medical records.
Some denial myths:
"they deny everyone the first time out". Nope. If you meet the criteria in your contract document, you are approved. Period. The catch here is that the insurance folks won't lift a finger to connect any dots, either. It's got to be crystal clear how you meet their requirements. If they can't distill the info from your charts, the likelihood you'll be denied goes up. Here is where your recent, clearly documented height and weight really become your friend.
"if you are denied, game over". NOPE. the appeals process exists for each plan. Use it. Some of it is silly (like when a plastic surgeon reviewed my file and found me ineligible) but it's there for YOU. You may have to play the game for awhile in order to get to a level of appeal where you can have your case reviewed fairly, but that level does exist.
"WLS is specifically excluded so game over". Not necessarily. My brother in law is in this situation right now and I'm trying to persuade him to FIGHT. In this case, I would go to an advocate because they can help you navigate this process. My *understanding* is that through the use of the appeals processes, you can get your case in front of an independent review board where your case will be determined based on medical necessity, not bean counter standards.
Good luck to anyone just starting out!
Laurie
(disclaimer: I'm not an advocate, an attorney, health care insurance expert, etc. I have no relationship with any advocates, other than I hired Lindstrom's to handle my case. I'm an average girl who gets frustrated with people who give up much too early, or worry about things they actually can control)
1. First thing: get a copy of your insurance plan requirements in writing so you know exactly what you are up against. If you meet the requirements *in that document*, you will be approved, period. It amazes me the number of folks who have never seen this document. Contact your HR office. They should have it.
2. Get a verified height from your PCP or surgeon at the beginning of the process and use that for your BMI calculations. That is the height you want your insurance to use. Don't cheat, but make sure that you are not attempting to do your best supermodel impression, either. Height is not your friend at this point. I had a variance of 1.5 self reported inches over the years in my various medical records.
3. It is also in your best interest to weigh heavy. Again, I am not suggesting you cheat, but wear thick pants, heavy shoes, etc. that day. You get the idea...
4. Regarding denials: I had 2 of them, plus my first surgeon's insurance coordinator told me there as nothing else she could do for me, which was BS, but that is a different story. I hired an advocate (Walter Lindstrom) to get me through the process because I didn't have time with work to be able to stay on top of it. Can you self advocate and manage your own appeals? Definitely, but the path I took was the right one for me. If you do manage your own appeals, pay VERY CLOSE attention to dates and back up your assertions with facts from your medical records.
Some denial myths:
"they deny everyone the first time out". Nope. If you meet the criteria in your contract document, you are approved. Period. The catch here is that the insurance folks won't lift a finger to connect any dots, either. It's got to be crystal clear how you meet their requirements. If they can't distill the info from your charts, the likelihood you'll be denied goes up. Here is where your recent, clearly documented height and weight really become your friend.
"if you are denied, game over". NOPE. the appeals process exists for each plan. Use it. Some of it is silly (like when a plastic surgeon reviewed my file and found me ineligible) but it's there for YOU. You may have to play the game for awhile in order to get to a level of appeal where you can have your case reviewed fairly, but that level does exist.
"WLS is specifically excluded so game over". Not necessarily. My brother in law is in this situation right now and I'm trying to persuade him to FIGHT. In this case, I would go to an advocate because they can help you navigate this process. My *understanding* is that through the use of the appeals processes, you can get your case in front of an independent review board where your case will be determined based on medical necessity, not bean counter standards.
Good luck to anyone just starting out!
Laurie
(disclaimer: I'm not an advocate, an attorney, health care insurance expert, etc. I have no relationship with any advocates, other than I hired Lindstrom's to handle my case. I'm an average girl who gets frustrated with people who give up much too early, or worry about things they actually can control)
Sleeved 6/12/13 - 100 pounds lost to get to goal!
It all depends on the details of your plan. I am inclined to say probably not, but there may be other restrictions in place like a supervised diet that you will need to meet and until they are completed and documented, they will deny.
Restriction/requirement details will vary by the employers plan, so with YOUR plan document, you will know all of the criteria you need to meet.
Good luck!
Restriction/requirement details will vary by the employers plan, so with YOUR plan document, you will know all of the criteria you need to meet.
Good luck!
Sleeved 6/12/13 - 100 pounds lost to get to goal!
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