insurance denied HELP

My insurance company denied my pre cert. THey said it wasn't serious enough and I hadn't tried enough non surgical avenues. I am going to the hospital in the am to talk to the financial people I have to stop this pain. If i can't make something work i just don't know what i will do? I'm just about to go out of my head., Help!

Hi, I'm so sorry that this happened to you. I know that you're upset and disappointed right now. I think that you should call your dr and see if he/she can call the insurance and give them more details about why your surgery is necessary. I've heard from other ladies that that has worked for them. I've read a lot of times that an appeal to the insurance has reversed the decision.

Best wishes, please keep us updated.

s

I know what you are going through, believe me. I just got done dealing with this myself. My dr. submitted a pre-cert and it came back denied. We faxed additional information, denied again. My dr. sat and had a long phone conv. with the med. director and it was still denied. So I appealed. And yesterday I found out I won my appeal. My surgery was to be Feb. 26th. My insurance said I did not meet their requirements on one of the diagnosis listed, and for that, they were denying me. It is SO HARD dealing with this. I have been so stressed out the last 6 weeks. Anyway, I appealed, and an independent committee reviewed my appeal, they sent it to an outside ob/gyn in Oregon to get an opinion, my dr. copied my entire medical file and sent it, and I wrote two letters and to my surprise, there was enough evidence to warrant the hyst as medically necessary. I got my authorization number today. I have a new date now, and although it was so hard to see that surgery date come and go (the first one), I certainly don't mind waiting now knowing I have an authorization number and I am for sure having surgery this time around.

I would go to your doctor. See if he can do anything. That might be all it takes. If not, try the appeal. I am still in shock that mine favored my way, but if I can battle insurance and win, there is hope for others.

It might take a little more time, and some work, but in the end, it can be worth it. I would have never been able to afford having the surgery without an approval by insurance.

Please let me know how things go. You can PM me if you want to talk more. I know how it feels to hear that denial. I said it was like a part of me died...it sounds dramatic, but it is such a mad, sad, hurt feeling. Like you are not worthy of having a quality of life that you deserve. So many nights I cried. I prayed. I was so irritable and depressed. I was so happy yesterday when I got notice of my approval I just broke down with tears of joy.

Take care

Erica

I just talked to the hospital and the dr and they are going to try to see if they can set it up on a payment plan. The lady I talked to said she didn't see why not but her bosses might say no. I should know for sure before noon. I can stand paying 50 - 100 a month or more if I have to just to have this pain and misery go away!!








TVH 3/5/04 maybe

Just a suggestion: I would have your doctor do all he/she can to get payment authorized before attempting to self pay if at all possible. at 50-100 per month, you would be paying it off for a long time. I just got the bill for my hospital stay alone.....Now I'm fortunate my insurance picked up the tab, but this was a little over $10,000 alone for just a two nights stay.....This is not including the surgeon, and anaesthesiologist fees, plus bloodwork, etc.

I do not mean to frighten you, or add to your stress level in any way. I work for a managed care co, and what I can tell you, is that squeaky wheels get the oil. Keep going up the chain of comman with your doctor involved.....It will work.

I would write a letter, myself, to the insurance company. Explain to them how your quality of life has been interrupted. I did this to have my TMJ surgery and once they got the letter they changed their mind. Tell them each and every aspect of how your life would change with the surgery. Send a copy to your doctor. My doctor took my letter to a board of director's meeting with a physical therapist's group in my state and he told them that by doing that, my surgery would be approved. A couple of weeks later, I got the call. It was approved! Good luck. Let us know what happens!

Jenny

Please don't give up and just pay for the surgery yourself! I'm pretty sure you can get them to change their mind if you appeal. I think they just automatically deny claims hoping that people will give up. If your Dr. will go to bat for you, and you are determined enough, I'll bet you can get it approved.

i AGREE. Do not give up & pay for your surgery, Go back to your MD and have him write additional documentation. Include a letter from yourself, if you wish. And keep fighting them! Appeal, appeal, appeal !Contact the consumer reporter at your local TV station. They love stories like this !

Good luck !

Hi,

I know this is hard, but there have been instances where having surgery denied the first time has actually proved to be the right decision. You mention that you want to stop the pain - there is no guarantee that a hyst will do that, sometimes it's trading one set of problems for another.

None of your posts say what your symptoms are, or what other treatments you've had so it's hard to answer your question. As unfair as it may seem, the insurance company does have the right to request that other treatments be tried before they ok surgery, unless your DR can convince them that the condition is too advanced. If you review your program documents you will see that.

I have never worked for an insurance company, and I never plan to, but in their defense - if you read your agreement with them they have the right to be sure that elective surgery, such as a hyst, is the last medical treatment that there is. Unless cancer is suspected a hyst is elective surgery. If it was entirely the bottom line they were worried about, they would say yes to every hyst before any other treatments were tried. The fact is they do get blamed for unnecessary hysts, some hysterectomy opponents say they are too quick to give the ok.

There has been concern that in the past way too many unnecessary hysts were being performed without giving alternatives any thought at all. The medical community came under fire for that, and it can be said that the insurance companies are responding to that by trying to make sure that a hyst is the last alternative.

Check out this thread: scroll down all the way to the post by ojazz for the other side of the coin. https://www.hystersisters.com/vb2/sho...ight=insurance

Best wishes

The problem ladies is that my insurance will be gone in about 3 weeks when my divorce is final and right now is the only time i can get enough time i can miss in school ( RN program). I will be out of RN school this time next year so paying it off will not be as bad as it could be. And i have to work this summer that is when my boyfriends kids arrn't here.
So i am having it in the morning anyway. THe doctor and hospital are still trying to help though.