Costco-size can of whoopass

I'm ready to open one on the insurance company.

I got another statement in the mail today, and they are now denying my psychological evaluation in its entirety, to the tune of $520.00. (!) They are claiming the service was not only not "preauthorized", but that it was performed by an out-of-network provider.

I stood right next to the office person in the provider's office while she "preauthorized" it, the day it was scheduled, and specifically used this provider--out of several in the office--because he was the only one covered by my insurance. (I didn't even want to go to him! He wasn't terrible or anything, but I prefer to see female medical professionals whenever possible. It's a my-own-comfort-level thing.)

So I called the insurance company, who told me that this provider is not in network under his tax ID number. They also told me the claim had been forwarded to the behavioral health division. I explained for the 5,000th time that it was a medical claim, not a behavioral one, which they concurred, and which doesn't help me one iota since he is apparently not in network.

WHY would the office person tell me the provider is covered if he isn't? Did she pretend to talk to someone on the other end of the phone while I stood there? I'm stumped. I called the provider's office, and of course the billing person isn't there until Monday. Conveniently, Monday is my next nutritionist appointment, so I guess I get to take this up with the staff in person. (Oh, joy!)

If I have to pay this entire amount out of pocket, at least the tax return is coming, but it makes my going back to school an elusive pipe dream. I guess I will go through the motions of applying just the same, in the hopes I can still get in and receive student loan funding.

This certainly removes any mystery surrounding the reasons that, on any given day, I'd rather crawl back under the covers and stay there, or sit in a nice, dark, silent room with no other people in it. Pffffft.

The awful truth

This is a typical occurrence following every. single. bloody. appointment. I've had thus far:

1) Letter from husband's insurance comes in the mail. Letter says as far as they know I have my own health insurance and to please provide them with further information. (I have called them and provided them with said information at least eight or nine times, and they have been covering my prescriptions without a question since last June, when my own health insurance was no more.)

2) I call the insurance company. I try not to be pissy and probably fail in tone of voice, but say please and thank you and have all my information conveniently at hand. I have to speak slowly and clearly into the clown's mouth to get routed to the proper agent, who may or may not route me to one or more agents or divisions, who may feign surprise, make reassuring yet noncommittal sounds I am convinced they send them to training specifically to learn, apologize, or not. It's a white-knuckle rollercoaster ride of fun and frolic, let me tell you! (Is this kind of unbridled excitement why people love to gamble? I like my money too much to ever let go of it long enough to find out.) I always wonder if I'm *really* being recorded or monitored for quality assurance.

3) Every single solitary time the claim I am calling about has been a covered service. I don't go to out-of-network providers; at least 95% of the time I check ahead of time that things are going to be covered.

Today's wrinkle is that they are trying to bill me for the psych eval that they required prior to this surgery. I specifically went to the only provider they covered at the wellness center because he was the one they covered; if I'd had my choice, I would have gone to a female practitioner, because that's just the way I roll.

So I call the behavioral/mental health division and tell them what's up. They tell me it's a medical claim because it's relating to the bariatric surgery. They also try to tell me the provider isn't in network, and I cut them off at the pass. They transfer me to the medical division.

The medical division listens to the situation and tries to send me back to behavioral/mental health and I say no, this evaluation was ONLY performed because it was a required step prior to bariatric surgery. They hem and haw, put me on hold to research it, and then come back on and say they will have to research it further and then call me back. So now I get to wait for them to call me back.

(Fittingly, I bought a copy of Michael Moore's movie "Sicko" the other day; I am a big fan of his films in general, but have a feeling this one's going to be my favorite. I will never forget when he had his TV show "The Awful Truth" on Bravo--the most memorable episode for me featured a man--the father of a small child, and he may have been her only surviving parent, if I recall correctly--whose health insurance provider refused to pay for an organ transplant that would save the man's life. Moore staged an elaborate mock funeral for the man on the lawn of corporate headquarters, complete with casket, pallbearers, the works. Following this, the insurance company paid for the gentleman's transplant.)

Official denial letter arrives amidst Ambien CR withdrawal

My official hard copy of the denial letter arrived from insurance today. Basically, I meet all of their medical necessity criteria, except the six months of supervised diet and exercise, which I knew--and apparently, that is their sticking point.

Their criteria for deeming bariatric surgery medically necessary is as follows:

Age 18 years or older;

Body mass index (BMI) of 40 or greater or a BMI of 35-39.9 with at least one co-morbidity including but not limited to cardiovascular disease, type II diabetes, hypertension, coronary artery disease, or pulmonary hypertension;

Active participation within last two years in one physician-supervised weight-management program for a minimum of six months without significant gaps that includes monthly documentation of the following: weight; current dietary program; exercise program.

Recent evaluation by a multidisciplinary team including all of the following:

A recommendation for surgery for treatment of morbid obesity by a bariatric surgeon;

A separate medical evaluation recommending bariatric surgery;

Clearance for surgery by a mental health provider;

Nutritional evaluation by a physician or registered dietician.

I assume these criteria are typical requirements for any health insurance that actually covers bariatric surgery.

The letter wasn't alarming in and of itself, but did include a passage that stated no services denied as medically necessary would be covered per their contract. I am hoping that doesn't mean all the preliminary appointments listed above that have already been completed, because I will fight tooth and nail if they try to deny those things--I only did them because insurance required them, after all. Since the providers call before every appointment to see if it is covered--and since they have said "yes" every time--I doubt the charges could be denied for any of this stuff. Given my past experiences with this insurance, however, I notice they have to be called and reminded someone is reading their policies, statements, and correspondence in order for them to actually fork over the dough.

***

It's been a weird few days--this is the first time in about ten years (save a day or two here and there) that I haven't taken any kind of sleeping pill. I am glad to be getting this stuff out of my system, because if the way withdrawal feels is any indication, I doubt it was doing anything good in there. I couldn't sleep at all for the first three days, then I crashed for about 12 hours. The past couple of days I have been sleeping in long blocks of time--today I could barely rouse myself at all. I've had cottonmouth and tingling hands, and the dreams I've had have been really vivid and intense, like being in the middle of 2 or 3 movies mashed together.

Insurance denied surgery today

Insurance turned it down flat. They want their six months of a diet. I'm in the middle of it, so no harm done. A little discouraging, but I wasn't expecting miracles.