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Insurance Denied Insurance Denied

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Unread 03-22-2006, 01:18 PM
Insurance Denied

I am almost 45, anemic with very heavy bleeding each period. Some pain and a history of ovarian cysts although none showed during my ultrasound. I saw my GYN March 1st - she scheduled a hysterectomy for April 3rd - also sent me to colon specialist (colonoscopy was fine.) Then sent me to a urologist who diagnosed bladder prolapse and is planning to do a bladder repair during my hysterectomy.

Well - I posted here a few weeks ago when my GYN called and said the insurance denied the claim. But she said not to worry - this company does this all the time and she'll call them back and talk to them to appeal. I have called her office half a dozen times since then and been told she hasn't had time to call. This morning I called again - the scheduler called me back to say that my GYN doesn't think the insurance company will OK it and that my GYN will call me this afternoon to talk.

First of all - why has she let this go on for so long? I've told my boss my surgery date - my family has made plans to travel to be with me and my husband has scheduled to be off work. My preop is next Monday. NOW she's going to call & tell me she never even appealed the denial?

I think she will want to do an ablation - but I've read where such a high number of women end up having a hysterectomy later anyway after ablation. Some continue to bleed. I'm anemic and I'm tired. I want this taken care of now. I've had surgery (albeit 15 years ago) to remove a ruptured cyst on my ovary. I've had other surgeries and I know that I want this historectomy so that I don't suffer anymore. I'm tired of having to wash my sheets during my TOM. I'm tired of being tired.

Has anyone had to deal with this? I thought I would be having this surgery a week from Monday. What should I say to her when she calls? What do I do next????
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Unread 03-22-2006, 01:47 PM
Insurance Denied

I'm so sorry to hear that your GYN dropped the ball on this. That must be so frustrating!
When she calls, I would try to keep my cool (would be very hard for me!) and ask why she never took the time to make the appeal on your behalf. I don't think, personally, that there is any reason that would be good enough but you should at least hear her out.
If she does suggest doing an ablation then I would tell her your views on that and don't let her bully you into doing something you don't want to do. Tell her you would rather fight the insurance company and that you've already made many changes to your schedule...not to mention your family's schedules...for this surgery and it really is leaving it to the last minute to cancel.
If you truly want this done and she is a supportive doctor she should try to the insurance and ask to speak to the Medical Director...something. There is still time to make those pleas.
If all that does not work out or she is not willing to be an advocate for your well-being, then you will, unfortunately, have to cancel and I would seriously consider finding another doctor who will.
Let us know how the phone call goes and what decisions are reached. I will be keeping my for you that it will be the outcome you hope for.
Take care.....
Unread 03-22-2006, 01:51 PM
Insurance Denied

If I had not tried all of the alternatives available to me, my claim would have been denied too. I hated it. I was in terrible pain for close to a year. But there is no way I could have taken on another $10,000 to $20,000 in medical bills. The Dr was still worried that they would not pay because all of my tests were good.
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Unread 03-22-2006, 01:56 PM
Insurance Denied

Have YOU called your insurance company? I requested my dr. write a letter and fax it to me, which I faxed to the insurance company along with my first appeal. The insurance company upheld their decision- Feb 17th (my first scheduled surg was to be 2/21/06). I immediately wrote another letter demanding a second level appeal- requesting that my appeal be revisted within 24 hours (that is your right to request). We did a LAP on 3/1 because that is what insurance wanted, even though I knew it was unnecessary...we did it, and I got a letter dated 2/28/06 approving my hysterectomy for 3/15-which we had already cancelled because of the LAP.

I took control of the insurance issue, because I knew I was the only one who really had my best interests at heart. I knew that I was the only one who cared if I hurt or bled all the time.

My letter had a lot to say about quality of life, and how I am being robbed of it, and about other procedures just being a temporary fix, and would they (the insurance folks) let their doctor put a BANDAID on their child when their child needed STITCHES?...

Call your insurance, find out WHY they are denying, and WHAT you can do about it.

Good luck to you and keep us informed.
Unread 03-22-2006, 06:08 PM
Insurance Denied

She didn't call. I shouldn't be surprised, should I?

I'm not sure what to do next. I think I will call a different doctor and start over. She has been my doctor for three years and I like her, but I think she has been very unprofessional. Not to mention that if I have problems after surgery and she doesn't return my calls I would be even more upset.

I still don't know if I should go to the hospital Monday for my pre-op & bloodwork. I would think she needs to cancel that?

Oh yes, I did call my insurance company when I first learned they had denied the claim. They told me it was best for my doctor to call them back to discuss any appeal with the Medical Director.

Should I just call in the morning and start over with a new doctor??? What about the Urologist she sent me to who is supposed to do surgery with her? I go back Friday for a cystoscopy. I had a Urodynamics test done Monday. arggg....

Thanks for the support.
Unread 03-22-2006, 08:12 PM
Insurance Denied

O boy-----------sorry to hear of all the mess with insurance and doc's. Maybe the urologists can refer you.????

Sleep on it and in the morning after you have rested your head will be clearer and ready to take the next step---I would work on all my options. Call and talk with who ever will listen and decide what the best direction for you is.

Nothing is ever easy is it? Just keep plugging along and as we know all things work for good--this to shall pass.

Blessings and good luck to you!!
Unread 03-22-2006, 09:12 PM
Insurance Denied

I went through a similar experience. I was abandoned by my OB/GYN who deliverd two of my children. He told me that he wasn't willing to write an appeal on my behalf. I got a referal for a second opinion and went with the new greatest Dr.

Call your ins. and ask for them to send you their policy and procedures for this particular surgery. What symptoms qualify and what are they needing to be done before you can have it. Also, look on their website. They should have a link to their manuals of policies and procedures. Ask your Dr. or I suggest a new Dr. for the procedure codes and use these codes on the ins. website search engine. You should be able to see what is allowed and what is not. Maybe a new procedure code would work. It did for me. I use their website for everything now knowing what is covered and what is not really helps when you feel like your up a creak without a paddle.

:wow: If you do get a new Dr. when you call the ins. MAKE SURE you tell them that you are talking about the new Dr. When I called they thought I was talking about Dr. #1 when in actuallity I was talking about Dr. #2 the new greatest one. This delayed the approval.

You may have to jump through hoops. It's the ins. way of trying to solve problems without the major fix. Annoying. My resulted in an approval for surgery after doing all that was "conservative" and my new, greatest Dr. wrote a convincing appeal on my behalf. Everything else we did wouldn't work. He too, didn't think that I would need the surgery but he was willing to help me and they made sure that I wasn't going to be abandoned.

My new, greatest Dr. also did an LSH because I was a candidate for it. They (Dr. and assistant physician) said it takes longer during the operation than the abdominal, but you heal faster and without major incisions. I am forever grateful for them taking "time" for me.

Hope this can stere (sp.?) you in the right direction. I wish you find a Dr. who has compassion and is passionate about his/hers patients. Feel free to send a private message if I can be of assistance.
Unread 03-22-2006, 10:45 PM
Insurance Denied

I'm so sorry to hear that you haven't heard back from your doctor yet. I also think she has behaved unprofessionally.
I think midwestcaregive's advice is good.
Sleep on it and in the your doctor back and if they won't let you speak to her then I would go to her office and wait until they get her for you. See what she has to say.....if you have decided to find a new doc then explain your reasons for it and find out if she will be canceling everything or if that is up to you. Ask where the release form is for your records and sign it so you can have a copy for your own records and to bring when you find a new doc.
Maybe try the urologist's office to see what they say?
I really don't know...probably sleeping on it is best for now.
You could call your insurance company and request all the info Imokay suggested so you at least know the reasons why and where to go from here.
I'm just so sorry that your doctor has such disregard for you as her patient.
Wish I could be of more help.
Here's some s for you.
Keep us posted on how things progress for you.
Unread 03-23-2006, 07:09 AM
Insurance Denied

Your insurance company has to talk to you. They have to generate a letter that explains in DETAIL why they denied your surgery. I agree with the ladies, if you doctor is not willing to fight for you, then you need to find a doctor that will stand behind you.

You can write a letter to the insurance company to appeal also, that is your right.

I truly hope you find a doctor who will carry the mantle for you, and fight this battle beside you.

Good luck, and keep us informed, it may take a little time, but it will work out.

Unread 03-23-2006, 11:39 AM
Insurance Denied

It is all about your surgeon he or she can make or break the deal. I made a statement in another post about how some doctors can act and some of the sisters were not happy. I've worked with them for years, some are better than others of course. On a bad day they can be the surgeon from hell and what you see in the office is not always what you get. Sorry things are not going well for you.

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