Tuesday, January 21, 2014

Day 8 - Theresa Vs the Volcano

Well, not the volcano, but her her health insurance company.

When I decided to get this surgery, I of course contacted my insurance company to make sure I knew what was necessary to be covered.  I contacted Bill's as well.  I ended up with a page long list of things that I had to do before hand to be qualified.  The list ranged from things like a doctor's letter with my weight for the last 10 years, 6 months of a doctor supervised weight loss program, psychological testing and so forth. I was assured that as long as I followed the plan, I would have no problems.

This was probably in late June 2013 or early July.  I immediately made appointments with my primary care physician, went on a diet and started working the list. If you have ever known someone who had done WLS (Weight Loss Surgery), you know that there are many hoops to jump through.  I finished the final hoop on Dec 13, 2013 and the final paperwork was submitted to the insurance companies.  Surgery was scheduled Jan 13, 2014 at 6:30 am.  All I had to do is wait a month and do the pre-diet. Little did I know that the fun was just starting.

On New Year's Eve, around 2:00 pm, I received a rather disturbing phone call from the surgeon's office.  They needed to "convert" my surgery to gastric by-pass so that insurance would pay for it.  I deliberately did not choose by-pass.  I didn't like some of the side effects, including the malabsorption issues.  I already have malabsorption issues with the pernicious anemia.  I don't need more.  I didn't choose the Lap-band because I really really don't like the idea of permanent man-made materials being left in my body.  If I didn't have VSG, I was going to just not have surgery.  Immediately, I called my health care coordinator at the conference office - but only was able to leave a voicemail.  I called my insurance company to no avail.  The people in the call center were polite but just not capable of helping me.  I called the GBOPHB (General Board of Pensions and Health Benefits) and talked to several people.  I called the Georgia Insurance Commission, but I could not really resolve this on New Year's Eve.

On Jan 2, I began calling again.  I was most displeased with the insurance company. Their call center employees are not at fault - the fault lies with those who wish the customer to NEVER talk to anyone who can make a decision.  EVER.  I finally talked to a customer service rep who asked if I had filed an appeal - I didn't know I could do that.  So she gave me a fax number and told me to get the doctor's office to write a letter and mark it "URGENT."

The doctor complied but didn't mark it URGENT.  They tried to recall the letter and do it again marked urgent, but was told by the insurance company that the letter had already been received, a file had been opened therefore it was too late. They guaranteed that we would hear back in 30 days!  Surgery was 11 days away - no way was I just going to sit and wait.

I called the Georgia Insurance Commissioner's office.  I was offered an opportunity to begin a case against the insurance company and would hear back - in 30 days.

That Thursday I also talked extensively to the General Board.  They were most helpful.  We discovered on the insurance company's website their own qualifications for 2014 - and that VSG was indeed a covered surgery.  We both searched online for the previous document - the 2013 - under which I was originally told that the surgery was covered.  I couldn't find it, but the General Board did.  It seems that VSG was NOT an excluded surgery in that document.  However, when we submitted the final paperwork, it was also NOT included under approved surgeries.  VSG did not appear in the document at all.  This was the basic problem.

On Monday or Tuesday, the doctor's office marked the appeal "urgent" and submitted it again anyway - by Wednesday they were told that it did not qualify to be urgent and we would hear back from them - guess what - in 30 days.

So the Doctor's office decided to go with my husband's insurance instead.  By Thursday, they had approved the surgery, but with a LARGE deductible and co-pay.  You see, we had decided to go with an HSA this year instead of a PPO for his insurance because my insurance was so much better.

AND - just as an aside - all this time I am working on my full-connection paperwork.  150 plus pages of papers, 10 DVD's - you know, nothing much at all.  So on Thursday I went and visited conference office and talked extensively to Karen in our benefits office.  What a lovely woman!  She reassured me that we would work it out.

And it was worked out.  Sometime after 4 on Friday (remember that surgery is Monday at 6:30 am!) I received a phone call that insurance would indeed cover my surgery.

Horrible story.  Torturous story.  Worse than the full connection papers. More stress than Christmas. But now done with.

No comments: