Tuesday, January 17, 2012

Bariatric Betty plays Beat the Clock

My husband used to feel like he had an ulcer every Sunday night when he heard the stopwatch clicking on "60 Minutes".  That's when he decided he should probably look at changing jobs and went from being a pharmacist to an IT guy.  Now I hear an imaginary clock ticking, and it's keeping track of how long it's been since my packet was submitted to the insurance company for pre-approval for RNY surgery. 

My patient care coordinator at Hospital C, Diane, said it we would hopefully hear back in less than two weeks.  That was 12 days ago.  I checked in with her last Friday and she said she hadn't heard anything yet but she would follow-up this week.  Yesterday was a holiday, so today I sent her an email and asked if would be an obnoxiously bad idea to call my insurance company myself to see if it had been determined yet.  She said she had planned to call them tomorrow, but would happily call them today.

So I got a call from her ......

And she said "They haven't scanned in your packet yet." 

Huh?  Apparently, the packet they submitted hasn't even been scanned into their system from the fax yet.  Then it has to be assigned to a nurse for review.  Then they make a decision.  Aetna said that they will move it up to being scanned ASAP since she called, and that a nurse reviewer should have it by Thursday (that would be the two weeks mark - but instead of having an answer, it will probably JUST be started to be reviewed).  So, before I could ask, Diane offered to call them on Thursday to make sure it has been assigned and see if she can get any other info (like when we could expect a decision).  I love Diane.

Did you know that people in Canada can wait for YEARS on the waiting list to get their bariatric surgery?  Painful, but true.  Of course, they spend that time KNOWING that they WILL get the surgery.  I've been waiting for 117 days so far just to see if I will qualify, dieting the whole time and trying to stay motivated while knowing that the insurance company may say "No".

It's a win-win for the insurance company if they cover it - their policy limits them to $15,000 max for life for bariatric surgery.  Just considering the cost of my medications and supplied for diabetes, they would make that back and not have to worry about hospital expenses for co-morbidity treatments.  But that's logic, not insurance policy.  If I'm denied, I will appeal. 

I heard an interesting fact from a Weight Loss Surgery vet who works for a different insurance company (not to be named).  She said that 9 out of 10 of their appeals get approved.  Right.  That leads me to wonder - if they are going to approve 9 out of 10 appeals in their company, shouldn't they just ask a couple questions and skip the denial process?  I would guess the answer is no because delays in approvals push costs further down the fiscal year, and because most people will never appeal - so that means no immediate costs. 

I understand the commercial model appeal of that concept.  It's like Old Navy giving out coupons for $10 off a $20 or more purchase a month from now.  They're betting 1) most of the people they give out the coupons for will lose the coupons or forget about them and 2) You will spend more money on the return trip since the you will be thinking "Hey, I'm going to get $10 free". 

Here lies my issue.  My health is not an Old Navy t-shirt.  My surgery is not something that can go on the clearance rack.  And unlike a trendy plaid skirt, my obesity will not go out of style - it will kill me. 

So I'm waiting, again.  Feels like I'm starting over the two week estimate again, and the last 12 days have already caused a lot of insomnia and stress.  I'm going to try to think positive.  I'm trying to work out more again, thinking "Any pounds I lose now are less that I will have to lose after surgery".  And they had better approve my surgery, because they don't want to have to deal with me during an appeal process.  I keep excellent documentation and WILL wear them down.  Think I sound determined?  You haven't even MET the stubborn side of me yet.

1 comment:

  1. In a way what you are saying about Canada is true but not always I sat on a waiting list only to have 2 surgeons retire and their waitlists dont get transferred