Question:
SHOULD I BE SCARED TO FILE A COMPLAINT WITH THE INSURANCE COMMISHIONERS' OFFICE?

BCBS OF GEORGIA DOESN'T WANT TO APPROVE ME BECAUSE I CANT PROVIDE proof of all my COMMERCIAL diet programs in the past. I have spent the last 2 days making phone calls.. Weight Watcher's doesn't keep records of past customers, Quick Weight Loss is charging me $35 and then I have to "wait on corperate" to send the proof... Jenny Craig and Tops were easier but what about OA? Does it even count? It's annonymous, I can't prove I went there! I have medical records of doctor supervised attempts and a very detailed diet history of my whole life (44 years) but apparantly this is not good enough! All my policy says is they will cover this if it is MEDICALLY NECESSARY, not if someone in the utilization management department feels like I have tried hard enough! I find this appalling! I have contacted the office of my state's insurance commishioner and they are sending me forms to file a complaint against my insurance company. Anybody out there done this? I am worried it will only make BCBS mad and they will delay more or just deny me completly, but I don't think this is right!! Do the insurance companies make heart patient's PROVE they really did have a blocked artery?? Another thing, I know someone else posted about this recently, but what is up with the insurance companies not letting US talk to the Medical review department? I was given the nurse's name who has my file but was told that she will not contact me at all. They only deal with the doctor's office. I don't understand this, I feel they should communicate this directly to me so I will know exactly what is required. Sorry this is so long.... any input, please!!! Thanks!    — Pam B. (posted on August 21, 2003)

August 21, 2003
Don't be afraid to go to the Insurance Commission in your state, but before you go, make sure that you have followed up with your insurance company as far as you can go. If you don't the Ins Comm will tell you to do that first and you could lose credibility with them. My sister has had to go to the Fla Ins Commission a couple of times about a chronic illness and going to them has seemed to help her.
   — M B.

August 21, 2003
I don't know how much I can help you b/c I certainly don't know all the answers, but I might be ale to provide a bit of insight. I work for Anthem BCBS of Maine in customer service so I deal with these types of questions every day. Insurance companies do have "medically necessary" requirements for all of the services they cover. This is to prevent abuse from people having services that are experimental, investigational or cosmetic. With the gastric bypass surgery, insurance companies are just starting to realize that this is not a cosmetic procedure for most people. I mean, those of us who are doing this are doing it for a lot more than our looks, right? Which leads me to ask: do you have any co-morbities? Anything at all such as knee pain, back pain, obesity-induced asthma, acid reflux (GERD), and a big one is sleep apnea. If you have sleep apnea and go to a sleep lab to confirm you have it, your insurance will almost definitely approve the service. I guess the only thing I'm worried about is your ability to "prove" you went to commercial weight loss programs. That's a tough one. If that is the ONLY reason they are denying your approval, then Quick Weight Loss, Jenny Craig and Tops should be sufficient. It's too bad you have to dish out $35 for Quick Weight Loss, but isn't it worth it at this point? Don't be afraid to file a complaint if you want to. People do this all the time and the insurance commission will investigate each and every complaint. But remember, it may be futile if the insurance company is truly following your certificate of coverage (aka your insurance policy). It won't make the insurance company "mad," and it is just illegal to delay a response (whether it's to uphold a denial or make an approval.) Regarding your question about why the medical review department won't speak to you...well, believe me, I know how you feel. But that's what customer service is for (even though I know it sometimes doesn't work). There are SO MANY requests that come through for prior authorizations and many of them are not even appropriate for that department, but they still need to looked at, touched, and forwarded to the correct department. This all takes time. The medical review nurses could not possibly do their reviews, work with the medical directors AND take calls from hundreds of people questioning this or that. I hope this helps in some small way. I truly wish you the best and I encourage you to stay on top of this.
   — Louise D.

August 21, 2003
In my opinion you do not need to have documentation of every last commercial diet attempt. The doctor supervised ones carry way more weight with the insurance companies. So focus on what you can get and the doctor's office notes and send it back in. If you are still denied for the same reason then appeal to the insurance company. Until you have exhausted their appeal process the state insurance commissioner won't likely do anything. <p>I had different experience with BC/BS United of WI. They allowed me to submit the detailed diet history myself and accepted it. However, in my case the two major attempts to lose weight happen to things that if they dig would find it in their files. The first related to a chiropractic claim appeal that went on for 3 years. I had lost 200 lbs on my own and in the process had a lot of back issues. So all of that weight loss was documented in the appeal info. The 2nd was the use of Redux, which BCBS paid for. So all they had to do was look for where they authorized the coverage of it. So maybe that's why they did not even question anything. I also at the same time they asked for this, was officially diagnosed with moderately severe sleep apnea. I think that sealed my approval, although it was likely a guaranteed approval to begin with because I blew all the national requirements off the charts for BMI and co-morbs etc. I got my approval the day after they got the diet history and info on the sleep apnea.
   — zoedogcbr

August 22, 2003
i had a similar problem with Cigna. I had to finally go toa second stage appeal before I was approved. Just try to provide as much documentation as you can. Cigna finally asked me to provide them with 12 weeks of records of documented participation in a weight loss program. They suggested weight watchers and I went there. I copied all my completed food lists, all my recorded weigh ins, kept an exercise record, and made copies and submitted the whole shebang to Cigna and then they approved me. At the time I was involved in later appeals I was given the name and phone of the nurse who was handling my case. I know this is frustrating for you but hang in there.
   — lianne R.

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