These mistakes can and SHOULD be avoided.

Common Mistake #1:
“I was told to ‘Just Call Your Insurance Company’ To Check If I Had Coverage

Calling Isn’t Always Enough

Handling over 5000 appeals teaches many things.  To be certain one thing we’ve learned is that calling an insurance company to confirm whether or not coverage exists is often the cause of problems.  Unfortunately, for most insurance companies, the people answering the  “Customer Service” 800 numbers are not interested in the problems of their customer, nor do they really care about providing “service.”  If that is the sole source of information upon which a patient or a bariatric program relies upon to perform surgery, several things can occur – and most of them are bad.  Too often the person on the other end of the telephone doesn’t know or understand the nuances of bariatric coverage, starting with whether or not it is a benefit in the first instance.  Some may say it’s covered “if medically necessary” but when you read the certificate of coverage, it’s clearly excluded.  Others will say it’s excluded and tell the member or the provider “don’t bother submitting a request or trying to appeal…”  Again, many times the coverage certificate shows, contrary to their verbal representation, surgery is covered.

Remember that a valid “pre-service claim” is done in writing and requires the company to provide a written response. Whether governed by state insurance laws and regulations or federal laws such as the Employee Retirement Income Security Act (ERISA), any determination made by a payer which is adverse to their member must specifically state the reasons for that denial, set forth in detail the appeal process and time frames to appeal in written form. Generally speaking, a customer service representative’s misstatement about coverage, even if it is relied upon by a patient, will not necessarily be binding on an insurer, especially if the plan language (which should be the source of learning about coverage), is clear and not ambiguous.  So patients and providers alike are wise to send the payer their written pre-service claim and get that written denial. It is often said “If it isn’t in writing, it never happened.”

Common Mistake #2:

ASSUMING EVERY CONTRACT EXCLUSION IS AIRTIGHT AND CANNOT BE FOUGHT

There may be times when a contract exclusion – a portion of the policy saying “we don’t cover weight loss surgery” – is written in a way that makes it difficult to defeat.  If you have a case like that, we’ll be the first ones to tell you.  However it is a mistake to presume that all exclusions are payer denials which are beyond fighting.  The fact is many can and are overturned.  The key is to make sure the patient’s request is submitted (in writing) and that it emphasizes medical conditions which are reduced or even cured when someone has weight loss surgery.  What kinds of medical conditions?  Here are some examples:

  • Type 2 Diabetes

  • Obstructive Sleep Apnea

  • GERD

  • Pseudotumor Cerebri (Intercranial Hypertension)

  • Hypertension

Depending on the way the contract is written there are also opportunities for “exceptions” to be requested.  Provisions for “Alternative Benefits” or “Case Management” often allow plans the discretion to cover things that are otherwise excluded.  However none of this matters if the patient doesn’t have a denial to appeal from.  So it is key for providers to submit these pre-service claims to the payer – even if they “know it will be denied” – to give the patient a chance to appeal.

Common Mistake #3:

INADEQUATE DOCUMENTATION SUPPORTING THE REQUEST FOR SURGERY

All too often we deal with denials that never had to be….and the only reason the payer denied is because either the member or the provider failed to give information which was readily available and which supported the request for coverage.  Often there is a lack of communication or understanding between a bariatric program and a prospective patient as to what information could be provided.  Simple things like chart notes from primary care providers or specialists treating obesity-related co-morbid diseases might turn the tide.  But either the patient never tells the program those records exist, or the program – having those records – fails to submit them to the payer in support of the request.  Failure of patient and provider both to use information which is available is one of the most avoidable, yet most common, mistakes that cause insurers to say “NO” instead of “YES.”

 

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