[AnneG]

I called my insurance company today to see if they had our plan benefits up
yet. It's been since November and we still do not have a booklet or any access
to what kind of benefits we have.
The insurance company said it just came up today as it wasn't up on Monday, and they said
Weightloss surgery is not excluded however -
weightloss management and/or surgery is only covered by pcp and not by any specialists which the representative then said she thinks that specialists includes dietitians and the like.
She recommended me call our human resources dept who in turn told me that I needed to get the information from Anthem.
After explaining the whole sordid ordeal to the lady at human resources she offered to call 3 way and ask them for me.
They again said the company is responsible for choosing coverage and the coverage states all weightloss management including surgery must be done by pcp and that a specialist excluded for weightloss.
So human resources asked them to research it because they are saying it's not marked as excluded- only that a pcp would have to perform bariatric surgery which I think is utterly ridiculous because that's like saying only a pcp can perform heart surgery.
Evidently I have Anthem of Ohio but I live in Va.
Any advice on this?

[MsVickie]

LOL!!!!!!!!!!!!!!!!!!!!!!


Sorry Anne I have to laugh LOL. Honey there is no way a PCP can preform any surgery unless its a very small one like remove a wart or somthing very small right under the skin and I mean right under it.

When the insurance companys change like yours did somtimes its hard to get a definate anwser right away as far as what exactly you do have. Your Human Resorce office acutally should have a copy of the policy you have and should have handed out the policy to the employees to the employees already. I do know that Anthem somtimes takes a bit to get it all sorted out on their end.

When I worked at a company we always had Anthem but somtimes would change the policy just a little and it would take a couple months for them to get it all straigthend out. What I had to do since I was the administrator of the office at the time was to go to the person we acutally bought the policy from and have him get on them to get it straigthen up immediatly. Why? We had employees go to the Dr and they would tell them Anthem said we had no insurance. I had to do this every time they would mess with it a little bit. The one time it got fixed really fast.......... the Drs wife went in to a Dr the second day after the policy was tweeked. He got a call and went off.... then he saw what I delt with each time.

So..... my advice..... Whom ever is the Human resorce person....... its up to them to get the policy working right. To get booklets of what type of insurance you have and what they cover. They need to handle it and handle it now. PCPs are family drs and not surgeons. Plain and simple. So put it back into the Human Resorces hands and pretty much tell them to deal with it. They should have already sent you an insurance card and you can go ahead and register it on line. There you should be able to see your entire policy. If it dont work then they dont have it logged in right. Dont worry it will get fixed. Anthem is nortorious for this with new policys however when they get it in they pay like they are supposed to. Good luck and dont back down.

[DocSanae]

I'd think the rep of the insurance co has it worng? I can understand requiring to go through your PCP for recommendation for surgery and the intial work up, but yes, to require the PCP to do bariatric surgery itself is absolutely ridiculous.
It might be better to get a printed copy of the contract, benefits and exclusions included, and sort it out.
If your company really included a clause that only PCPs can perform the surgery, then, there probably is a way to fight it, as it is the same as saying a non-certified person--even if that person has a medical licence--can do the surgery, which goes totally against medical ethics.

Hope this gets straightened out soon.

[MsVickie]

Doc that is what Im saying. The rep evedently didnt know what he or she was talking about and had to be new or wouldnt have said what they did. There is no way in the world the policy can be worded like that what so ever. That is why I had to laugh at that part.

The company has alot of work to do to get Anthem straighted out. They are a part of Blue Cross Blue Shield BTW incase you didnt know that. Its just a name they use.

[Katbeyer]

Sad to say, but that is a law suit just waiting to happen

[wishing]

Keep us updated...insurance companies do some crazy things...but this is RIDICULOUS!!!

[AnneG]

Aww thanks everyone. This has been really frustrating and I guess it's like Ms. Vickie said, it's a new policy and the beginning of the year so I'm probably the first one who has called with questions like this. Someone is supposed to call me back today with more information. I've had 3 different interpretations.
One said bariatric surgery is covered by only by the pcp.
Another said bariatric surgery is covered but not by the pcp-
and another said bariatric surgery is not covered but any services for weightloss and management are only covered if provided by a pcp. It will be nice to know where I stand at least tho I'm feeling like things might not go in my favor on this. Course there are options so, I'm keeping that in mind.

[MsVickie]

Anne I do think you will find it will all be ok once they get it all sorted. Anthem is one insurance company that does pay for WLS. It will however depend on the policy and if it does have a clause in it stating straight up it DOES NOT COVER WLS. However in the state of VA there is a law stating insurance companys cannot deny payment for it. This is the part that is gonna suck ok but within a months time at the very longest it should have it all in place and going to know exactly what benefits you do have. I feel sorry right now for the people on medication that has to have it filled once a month and wonder if they are paying the correct copays or not? Keep us updated on this. This was my old stomping ground dealing with insurances and being a nurse also I multitasked alot so I wanna know how this goes.

[AnneG]

Wanted to write a little update. I've been so exasperated and pretty
much felt like this was going to be hopeless even tho I was willing to
fight based on the principal of the matter.
I stopped filling out my packet info from the surgeons office weeks ago-
in despair- figuring what's the point but I continued to stay on top of it
with the insurance company and human resources.
Anthem kept restating that my insurance policy was worded so as to imply
all weightloss management and surgery which is medcially necessary
is covered so long as it is perform by the pcp and not a specialist.
Some of the people at Anthem were very flippant and would not
elaborate as to what that means exactly even when I tried to explain
how utterly ridiculous that was worded.
Some of the representatives at Anthem were extremely nice and caught
the ludicrousy as they were reading it exclaiming that they'd never heard
of such nonsense in a policy.
Human resources were pretty nice but it seemed like it was taking a long
time to research even if it was only just over 2 weeks.
They stated that they'd intended to offer the same coverage as we had previously
as much as possible and they weren't sure if it was intentional or a misunderstanding
with the wording that caused them to assume it was covered.
Well- I got a call today- they said it's in process of being rewritten into the policy
and they will cover it- IF a patient meets the medical criteria of medical necessity.
I can't tell you how happy I am. I mean, I know I still have a lot of work to do and
there could be any number of things that could set me back or cause extended
amounts of aggravation but- It is just so amazing to know that there is some hope
here where the situation has seemed so bleak.
And I just wanted to tell you all - Thank you for being here and being encouraging
and helpful. I really appreciate you all.

[Suzi-Q]

Congratulations! It will all be worth it.