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Also Thinking About Insurance Issues
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10-10-2003, 11:28 PM
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Guest
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Posts: 1,049
Hysterectomy: December 4th, 2003
Surgery Type: TAH
Ovaries: Removed both
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Also Thinking About Insurance Issues
I've been reading posts about problems with HMOs. I'm a worry-wart in general, but these posts are compounding my fears.
I, too have an HMO. Over the past 3 years, I've had five "elective" outpatient surgical procedures (all related to my foot--originally a bunion repair followed by corrections of a "snowball effect" of complications). Although the insurance never hinted at denial, they did require lots of clinical info from my foot doctor before approving.
I spoke with my Gyn doc two weeks ago. He assured me his staff takes care of all insurance approval issues, but states they usually make the call about 3-4 weeks before surgery, (mine was still 9 weeks out at that point). Then, as we were talking on the phone he said, "Actually it looks like they've already called your insurance and no pre-certification is needed". I didn't contradict him, but I work in a physician's office and know the hoops we must sometimes jump through to get things approved. I waited a few days and called my insurance company. I was told this procedure definitely DOES require pre-approval and that nobody from my doctor's office had contacted them yet. (I have a feeling my doctor was looking at some note from my ultrasound test accidentally). Now, I'm debating whether to follow-up with the doctor's office NOW to get them started on the process, or wait a few weeks (as the doctor said they usually do it 3-4 weeks beforehand). I know I need to trust that it will all go well and end up in my favor, but I'm paranoid that I've gotten myself psyched for this and may be let down! I don't want to "nag" the doctor's staff as I've been on the receiving end of that in my own office!
Any suggestions for how I should handle this?
Jay-Jay
p.s.: if it makes a difference, I've had 3 or 4 ultrasounds over the past almost two years. I have two fibroids which aren't growing and aren't "huge" but they are symptomatic. When he's not regulating my cycle on hormones, my periods are very heavy and frequent (although no documented anemia). I've also had recurrent painful functional cysts on my ovaries when not hormonally regulated.
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10-11-2003, 05:24 AM
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HysterSister
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Posts: 6,053
Hysterectomy: February 5th, 2002
Surgery Type: TAH
Ovaries: Removed both
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Also Thinking About Insurance Issues
Hi
You may want to call your insurance company. I called mine about 4 weeks before my date. They didn't have a request yet, but it was noted that I had called. They told me it is usually a quick process, and to check back with them in a couple of weeks. When I called back they had all the paperwork done. Actually the day after I called them I got the pre cert in the mail.
If he says they get it done 3-4 weeks ahead of time, check at that point and if the pre cert isn't in the works call your DR's office.
Best wishes!
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10-11-2003, 07:35 AM
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HysterSister
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Posts: 72
Hysterectomy: November 20th, 2003
Surgery Type: LAVH
Ovaries: Removed both
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HMOs and precert LONG
Jay-Jay,
I don't know which HMO you have (I have BCBS HMO), but I had an identical situation. Several weeks ago I asked the young woman at my doctor's office who handles all the precerts to please go ahead and do mine so that if it was denied we could appeal in time to stick with the original surgery date. She called me back and told me that my HMO doesn't precert for this procedure but calls it a 23-hour observation, and if I needed to stay longer then the HMO would determine at that time if an extended stay was medically necessary.
I called my insurance company a few days later to ask about this, just to be sure, and I was told that a hysterectomy DOES require a precert and that there was no record of contact from my doctor's office.
I then wrote a letter to my doctor's office explaining my concerns and what the person at the insurance company told me. I got a quick response with a "notification authorization number" from my insurance company for LAVH.
I called my insurance company to ask what the difference in a precert and an authorization was, and I was told "they're basically the same thing." I told her I had a "notification authorization number" and wanted to know what that meant. She said that number meant the surgery had been approved.
I'm not thick-headed; rather, I wanted to make CERTAIN that this surgery had been approved and I would not be paying for it later!
Maybe your situation with your HMO is the same as mine.
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10-11-2003, 08:28 AM
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Guest
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Posts: 503
Hysterectomy: October 13th, 2003
Surgery Type: TVH
Ovaries: Removed both
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Also Thinking About Insurance Issues
Oh Jay Jay
Monday morning you absolutely should get to nudging the gals at the s office. It is too easy for pre auths to get put on someone's desk-5 on monday, but only 3 get done, 6 on Tuesday but only 5 get done (now we are 4 behind) none on Wed, but she doesn't get caught up, then Thursday she gets 3 more and does one from her back pile.....get the picture?
This is how we fall through the cracks at the doctor's office. You might be done already, or you might be 8 charts down.
Sounds like you have enough data in your chart to fax over to the insurrance company to justify your request; insurrance companies love this kind of stuff, so I am hoping for you that it goes smoothly. Usually once pre-autherization is obtained it is good for 6 months- so a few weeks early wont hurt a bit but will buy you incredable peace of mind.
ASK FOR A COPY OF THE PRE AUTH THAT GETS FAXED BACK TO YOUR DR.S OFFICE FOR YOUR FILES.....
The other thing to remember is that most of the people in most doctor's offices are sweet young things that haven't a clue what this means to you- all they do is look up the ICD-9 code and fax off the paperwork- so if there is a denial make sure your doctor dictates up a detailed letter, (get a copy) and faxes that as well.
Why should you get a copy- because you can also write a letter of appeal if this is denied and in it you will DETAIL GRAPHICALLY what is going on with you and you will stress the quality of life issues that you are dealing with. Then you will fax your letter along with a copy of the doctor's letter.
I would do it this way because who ever reads your faxes first is not likely to have your "chart" in front of them, but if the letter is pitiful enough will order your chart and send it and the new letters up the ladder.....
And really stress quality of life issues, loss of consortium, (no sex)
ruined clothing, embarrassing situations, etc.
If it goes to arbitration or court you will have a stronger case. Juries love quality of life issues
Good luck, we are rooting for you, and everything you are learning now will be good for the future should someone in your family have problems, you will be a terrific advocate because of everything you have learned
Dilu
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10-11-2003, 11:05 AM
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Guest
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Posts: 1,049
Hysterectomy: December 4th, 2003
Surgery Type: TAH
Ovaries: Removed both
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Also Thinking About Insurance Issues
Thank you all for your replies. Honestly, if I didn't work in a doctor's office now, none of this would have occured to me. (Sometimes I think ignorance IS bliss)! My DH thinks I "create" things to worry about...he may be right! Also, since I do many of the pre-certifications at my office, (I also work for a surgeon), I know I wouldn't be put off or annoyed by a patient calling me about this. Therefore, I don't know why I'd assume that they'd regard me as a "pest". (Maybe I'm suffering from that "nurse as a patient guilt thing")!
I really doubt that approval will be a problem. Several months ago I even mailed a letter to my doctor outlining my continuing symptoms/problems so that he would receive it when he returned from vacation. He's been discussing surgery as an option since approx. January '02 (almost 2 years). It has taken me this long to give up on "conservative" treatment. My only surprise/disappointment in this whole thing is that when I requested it be done vaginally, he said it couldn't be. My uterus is "too large and nodular". He said because of this, he wouldn't be able to have a clear view up there and room to work. A little disappointing I guess, but safety is the #1 priority.
Thanks again for all the advice! Don't know what I'd do without you ladies!
Jay-Jay
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