We are often asked what the difference is and why it’s important for people seeking insurance approval for bariatric surgery.

Most bariatric surgery patients (like most people in the U.S.) get their health insurance coverage as part of the benefits offered to them by their employer. Generally speaking health insurance plans are categorized as either “self-insured” or “fully insured” based on how the benefits are funded (i.e., what/who is the source of the money used for paying claims for covered treatment).

FULLY-INSURED PLAN

Think of this in the same fashion as automobile or homeowners insurance. In those instances the insured pays a premium and if a claim is submitted, the payment is funded by the insurance company (e.g. State Farm, Allstate, Geico, etc.). Apart from uncovered items and deductibles the premium is the only financial obligation undertaken by the insured. Similarly, in health insurance, the employer pays a premium to an insurance carrier (e.g. Aetna, CIGNA, Blue Cross Blue Shield, UHC, etc.) and that company assumes all of the risk associated with paying covered health insurance claims for the employee group.

SELF-INSURED / SELF-FUNDED PLAN

In the case of self-insured (a.k.a. self-funded) plans, the employer assumes some or all of the risk associated with their employee’s claims against the plan rather than simply “shifting” that risk to an insurance company in exchange for paying a premium. Three in five covered workers are in a self-funded health plan. Self-funding is common among larger firms because they can spread the risk of costly claims over a large number of employees and dependents.

WHY DOES THIS MATTER FOR BARIATRIC PATIENTS?

It matters in several ways. First, you’re not always dealing directly with the plan even though the ultimate decisions about whether or not a surgery is covered may rest with the plan administrator (usually the employer) at the end of the process. Because an employer with a self-funded plan operates a completely different type of business and doesn’t know the first thing about processing health insurance claims, the plan will delegate that claims administration function to a third-party administrator (TPA).

Many times those TPAs are management companies which specializes in doing those functions for self-insured plans like Zenith Administrators, CoreSource or one of many, sometimes that claims administrator is an insurance company such as UHC, Aetna or CIGNA, etc. So, for example, if your plan documents say “Aetna,” your plan may be insured through Aetna or it may self-funded by your employer and merely administered by Aetna. That is one reason a patient may say “I have Aetna” and another patient says “Me too” thinking they have the same insurance while in reality they have completely different coverage.

Self-insured plans also have the ability to set-up their own criteria for when bariatric surgery is (or is not) a covered benefit.  Often that criteria is very different from what their claims administrator customarily uses when it is the insurer.  Appeals can be won because a claims administrator is wrongly using its own medical criteria instead of criteria called for by the plan. Appeals can be won, even in the face of exclusions when the plan administrator determines it is in the best interests of the plan as a whole to cover surgery for a particular patient. There are times when the plan language excludes treatment and the employer doesn’t even know it.  We’ve had several instances where our appeals have been presented to benefits committees for self-insured plans and when they become educated about the benefits of bariatric surgery for their employees they have the ability to revise the plan in order to cover everyone, not just the patient we helped!

One memorable example of what positive things can be achieved when you get to educate a self-insured plan came when we represented an employee of a Fortune 100 company in her appeal.  Although the claims administrator denied it through the entire process because there was an exclusion for bariatric surgery in the plan language, we had the chance to present the appeal to a committee and we were successful getting her approved.   What we didn’t know until later was that, as a direct result of her appeal, the entire benefit structure for this very large company was changed to include bariatric surgery.  We found this out when our client wrote us an email telling us a story I won’t soon forget:

“I went to the company holiday party this year and was standing in line minding my own business, when a woman I have never seen before ran up to me and started hugging me. I had no idea who she was. Turns out she was the wife of another employee. When she was done hugging me she took my hand, her voice cracked, her eyes welled up and she said: ‘Thank you for fighting so hard for your surgery, because if you hadn’t fought that year long battle, I wouldn’t have been able to have my gastric bypass, and I would most likely be dead right now.’ “She kissed my cheek and walked away.”

Now THAT is a victory!

 There can be a BIG DIFFERENCE between an “external” review and an “independent review.”

WHY IS THAT DIFFERENCE SO IMPORTANT?

Many times a bariatric surgery appeal is sent by your insurance plan to an “external peer reviewer” who often comes back with another denial.  Then they write you or your surgeon a letter saying “this matter was reviewed by an external peer specialist with expertise in bariatric medicine…” or something similar.

Remember that is part of the insurer’s “internal” appeal process so it’s controlled by them.  You can imagine whose side that “external” reviewer is on, can’t you?

WHAT SHOULD NOT HAPPEN?

Patients or their doctors’ office often just give up if this “external” reviewer upholds the insurance company denial.  They mistakenly think they’ve got no other option to fight.  That’s not true.

WHAT SHOULD HAPPEN?

 Make sure you get your appeal reviewed by a truly INDEPENDENT REVIEW ORGANIZATION (IRO) and have your case decided by someone who is not controlled by the insurance company or bound by the insurer’s rules and medical policy.

AND WHAT CAN HAPPEN THEN?

We get a WONDERFUL Friday morning email from a lovely person who just found out we helped them get their approval:

I WAS APPPPPPPPPPROVED!!!!!!!! The IRO overturned the denial!!!!!!!!!!!!!!!!!!!! I just got home from work and there was a letter from UPS from them. I’m a big baby right now over this. I’m going to run out of tissues, lol. I cannot thank you ALL enough. WOW!!!!”

Who’s Driving The Bus? Providers or Payers?

Imagine this scene:   Your body mass index is well above 40, you have several obesity-related diseases and you’ve tried and failed numerous diets over many years.  YOU ARE FINALLY READY to consider bariatric surgery.  You medically qualify for bariatric surgery and you are committed to making the changes necessary to make it succeed.  Your primary care doctor is very supportive.  Now what?

You go to a patient seminar for a respected bariatric “center of excellence” and get very excited about your surgical options – - you have a tool within reach that will help you meet your goal of achieving better health.  At the seminar you sign a couple forms, they copy your insurance card and you get an exciting phone call that your insurance covers surgery!  YAY, right?

You invest several hundred, maybe even over a thousand dollars going through the process your program requires:

• You pay for and complete a six-month diet [even though it’s not supported by evidence-based medicine]

• You pay for a sleep study because it wasn’t covered by insurance

• You pay a substantial share of the psychological evaluation because not much of it was covered by your insurance because the provider was out of network

• You pay your co-payment for the nutritional evaluation performed by a dietician

• You pay out of pocket for a physical therapy evaluation

But then you get the exciting news that you PASSED the program and they are ready to submit to your insurance!  YAY, right?

Now imagine getting a call from the program’s “patient advocate” telling you they won’t submit a request for authorization to your insurance company because you don’t meet the insurance plan criteria.  She tells you they won’t submit it because it would be denied.  Sadder still is that she tells you this in a way that doesn’t hide her total indifference to how DEVASTATING this is to you:

But you could tell she wasn’t sorry.  She was busy.  She was done with you.  Maybe she was “advocating” for someone else.  Maybe she even showed that someone else a bit more compassion than she showed you.

I wish I could tell you this was a dark fairy tale.  I wish I could tell you this never happens.  Sadly it is too real.

We heard versions of this story twice in the past week and a half from opposite parts of the country, prompting me to write this.  We hear versions of this story all the time, usually when that patient rejected by their provider wants our help to appeal this “denial.”  Imagine how frustrating for us to tell them that in this case the “bad guys” aren’t your insurance plan – - – at least not quite yet.

We work with compassionate bariatric providers every day, some of whom will read this and not believe this is a real story.  “This would never happen in our program.”  While I hope you’re right we’ve seen these rejections sometimes happen without the surgeon or program director having any idea their own staff is sabotaging their practice by limiting the number of cases.  They don’t know their judgment has been usurped by the “criteria” of insurance plans and payers. 

This rejection isn’t a denial you can appeal to the insurance company – they haven’t done anything wrong – at least not quite yet.  In many ways this rejection is much, much worse because it prevents that patient from starting a fight against the insurance company.  It prevents that patient from exercising their RIGHT to appeal any denial, a right all patients possess regardless of what elements of the payer criteria are not satisfied.  It is absolutely the wrong way to handle things.

Why would a bariatric provider not want to give that patient a chance to fight?  That question doesn’t have an answer which satisfies me.  It’s not a fight they have to spend time or effort on – all they have to do is submit the information they’ve got and get the payer’s answer.  Even if that answer is a resounding “NO” it is an answer the patient can appeal.  The provider stands to benefit greatly if that denial is overturned.  But to refuse to allow the patient that chance????  Instead they blandly say “I’m sorry” when they really mean “I can’t be bothered.”  It stupefies me.

I’m still naïve enough to believe that doctors and their integrated health care professional team should make decisions as to what is “medically necessary” and what treatment options should be explored with their patient.  I still believe health care providers should be the ones “driving the bus” – the ones calling the shots with regard to what is or is not “medically necessary.”  Certainly there are passionate providers and programs that truly do everything they can to help their patients get in the game and fight to get insurance coverage for the treatment which is right for them.  We applaud them and love helping those patients.

We hear from many sources across the country that numbers of bariatric surgery cases are on the decline across the board.  We hear it from providers, most of whom are performing fewer surgeries.  We hear from industry representatives who confirm their accounts aren’t as busy.  We hear it from medical societies and others supposedly “in the know.”  So if that’s true, and I know that it is, my bariatric surgery insurance tip of the day is to remember that a patient who needs bariatric surgery is NOT your enemy!  They are not a disposable item who can be tossed away because their insurance is “too hard.”  They are a person who needs, wants and deserves a provider willing to help them.  They need someone who will get them in the game; not sit them on the bench.  They need someone who is not going to hand the keys over to the insurance industry to make decisions about whether they should get access to care.
They need someone willing to DRIVE THE BUS.

FOR PATIENTS’ SAKES – PLEASE DRIVE THE BUS!!

I am sure President Washington authorizing the first U.S. Census or President Kennedy establishing the Peace Corps is important to mention.  And my friends in Nebraska are surely celebrating that they became a State in 1867 and why wouldn’t they?  After all, there wouldn’t be a College World Series without Omaha, would there?  I suppose birthday wishes are appropriate for Roger Daltrey (69? OMG!), Ron Howard (Opie is 59!) and I’ll even let Justin Bieber blow out his 19 candles because I have friends in Canada and, after all, someone must like his music.

BUT ABC News, and every other media outlet I checked

(OK . . . so I didn’t check any others but go with it, OK?)

missed the biggest news event which occurred on a March 1^st.

ON MARCH 1^ST OF 1996, I started a little solo practice in a 10’ by 10’ sublet office hoping I’d be able to support my family and while I was at it, help some people who needed helping and were not getting it.  I’m very proud to say that, 17 years later, that little shop is still doing both of those things and I am very proud of the work we continue to do!  While that solo practice has since become a corporation and the original practice name has changed, our core Mission and founding principle that patients need to be empowered to effectively challenge insurers denying health care remains unshaken and will never change.

So today is our 17^th Anniversary and a day to celebrate by looking back a little, and looking forward a lot.  I’d love to sit here and take all the credit for the good work which has been done and for what great work I truly believe our future holds.  However I can’t take credit simply because too many of you reading this know the truth and there would be a hoard of self-appointed “fact checkers” falling all over themselves trying to keep me honest.

Therefore I choose to celebrate this anniversary by saying “Thanks.”  There are so many folks who have helped us do what we do that’s it’s impossible to name everyone.  (And if you watched the Oscars this year you know the orchestra started playing “Jaws” when the speeches dragged and I’m afraid of sharks).  But I want to thank first and foremost, our clients – the people who have trusted us over 17 years to do our very best to help them get access to the care they needed.  That trust is sacred and though we haven’t always been successful achieving approval, we have been successful in trying our best.  Thanks too to the countless doctors, integrated health professionals, medical device and industry folks who have also trusted us with their patients – their customers – their livelihoods.   Many of you have morphed from “colleagues” to dear friends, confidantes and cheerleaders.  With your continued support we will keep doing what we do until insurance companies behave in a way that makes our presence unnecessary.  Sadly that day may still be a long way off.  Family is extremely important to us and ours keeps us grounded, embraced with love and filled with laughter.  We are truly blessed.

I may have started the shop seventeen years ago, but in no way is this about me.  First off, our practice is blessed to have the support of 2 fantastic people, Raquel Quezada and Linda Luquin, whose dedication to patients is truly unwavering and to whom I never say “thank you” either often enough or loud enough.

In 1996, when this all started, I had a 2 ½ year old daughter and only a prayerful dream of having a son.  Seventeen years later it’s hard not to look at Marissa and Jared at ages 19 and 15 and wonder about the impact this has had on them.  They have dealt with my traveling, being away from home more than I’d like, and they’ve seen first-hand that business ownership can sometimes be stressful.  Yet I know the impact has been positive.  How do I know that?  I know because I see the people who they are becoming.  My eyes well up with pride knowing my kids care deeply about other people and that their moral compass is pointing in the right direction.  I owe them so much for what they have given me these 17 years I don’t have the words to say what should be said; I just hope they will look back in time at what we’ve tried to do and they will be proud of our efforts.

By now one of you “fact checkers” knows it is a bold-faced lie for me to have written “I started a little solo practice….”  The heart and soul of this labor of love was, and always has been, my dearest Kelley.  Like all jokester husbands, I’ll tease about “the boss” or “she who must be obeyed” and similar drivel and people will laugh only because they know the truth:  there is no Lindstrom Healthcare Advocacy – no Mission to help patients fight insurers – no victories over insurance companies to celebrate – no 17^th anniversary blogs – there is NOTHING in my life that doesn’t start with her.  This practice exists because, for whatever reason the Universe saw fit, she said “Yes” when I asked her a very long time ago if she was willing to be together “from this day forward….”  I got lucky.

This practice exists because of her extraordinary empathy for the people we serve.  This practice exists because of her amazing ability to methodically dress-down an insurance company representative in a way that makes me so happy that I’m not the one she’s mad at.  This practice exists because she works 2 full-time jobs – business owner and Mother/Wife Extraordinaire – more ably than words can describe.  This practice exists because for her “Walk in Faith” are not just pretty words – they are the core of her Being.  Because of her, we’ve been able to support a family and help some people who needed helping and weren’t getting it.  It’s not “all about me” – it’s “all about her.”

Rarely does an occasion arise where someone like me gets to tell the world how extraordinary their spouse or business partner is.  I get to do both at the same time and don’t think I’m going to miss my chance!  I certainly don’t deserve her – our clients surely do, but me?  Not so much.  But I got lucky and because of my great fortune and Kelley’s wonderful generosity we all get to celebrate the 17^th Anniversary of this wonderful adventure!

Be well.

Rarely will something be written in this Blog upon which everyone can agree, but this is beyond dispute: I am not a rocket scientist. But it doesn’t take a rocket scientist to know that all too often a patient’s access to a particular treatment, surgery, diagnostic test, medication, medical device or care setting isn’t being determined by the education, training and experience of his or her treating physician or another qualified health care provider. With frequent tragic results and invariably delays of care that cost patients in so many ways those decisions regarding access to treatment options are driven by an insurance company – an entity whose business model is predicated on taking in as many premium dollars as possible, promising to pay claims when needed, and then working as hard as they can to make sure they pay out as few dollars in claims as they can get away with. THOSE are the ones making de facto treatment decisions regardless of their hollow pronouncement they are only making “coverage” determinations!

That’s a bunch of horse**** – [you all know what it is]!

Is my description of their business model an oversimplification? Of course it is. But does that make it wrong? If you weighed my little rant on a scale of 1-100 with 1 being a complete and utter fabrication with no basis in reality and 100 being the ultimate truth sought by philosophers and mystics, I dare say my oversimplification scores somewhere in the 65-80 range. There’s a lot more truth than fiction to the concept of payers denying care for purposes which, among others, line their pockets.

Of course this wouldn’t be a problem worth writing a single fragmented, compound sentence about if those payer decisions were well-reasoned, performed with only the patient’s best interests in the forefront of their corporate minds, and done in a manner consistent with current medical practice or even their own conduct. But it is a problem worth writing, ranting and raving about precisely because those decisions are all too often unreasonable, uncaring and devoid of any deference or respect due to a provider who is actually treatingthat patient. They are decisions which negatively impact patient care. They are decisions which stifle growth of technology which can help patients and their providers and they are decisions which lead patients to feel hopeless, helpless and desperate.

ISN’T IT HIGH TIME WE ALL JUST SAY “NO” TO INSURERS WHO SAY “NO”! ISN’T IT TIME WE ALL CHANNEL OUR INNER HOWARD BEALE FROM THE CLASSIC 1976 FILM “NETWORK” AND ADMIT THAT WE ARE “AS MAD AS HELL” AND WE ARE NOT GOING TO TAKE THIS ANYMORE?!?

For the moment let’s focus on the request for pre-authorization, that process required by a payer which compels their member to take hat in hand and plaintively ask “Mother May I?” to get coverage for the medically necessary treatment they’ve been prescribed. Insurers will sometimes respond and say it’s “not medically necessary.” Other times it’s considered “experimental, investigational or unproven.” Perhaps they’ll claim the service doesn’t need to be performed where the provider wants or maybe they’ll just obtusely claim it’s “not a covered benefit” knowing that really says nothing but also knowing many patients won’t know how even start to effectively challenge them. Payers hide behind myriad formulations of phraseology which boils down to “NO” – “Not Now” – “Not Ever!” “Now go away!”

I will admit they are sometimes justified; providers occasionally overreach / patients occasionally want something that might not be good for them. But that isn’t usually the case, even though payers are quick to point fingers at providers. It does not appear that any area of medicine is immune from the payer saying “NO”, whether one talks about innovative treatment modalities, so-called “disruptive” medical devices and related technology. Even treatments which were previously considered “standard” are seeing coverage eroding.

Recent history in spine surgery provides some timely and apt examples. Surgeons were surprised to see lumbar fusions for various indications such as degenerative joint disease, previously covered quite routinely, be suddenly denied in overwhelming numbers with payers doing their best Chicken Little imitation yelling that “the sky is falling” and claiming that more data was needed. That isn’t terribly different than the problems spine surgeons confront with (relatively) newer procedures such as artificial disc replacement in the cervical spine. Despite being called “a very well-studied procedure with multiple level I prospective, randomized, multi-center and blinded studies, all of which have been published along with excellent follow-up…,” (Biggest Coverage Issues for Spine Surgeons in 2013: Q&A With Dr. William Taylor of UC San Diego) access to cervical disc replacement remains more difficult than it ought to be given its acceptance in the surgical community. And trust me, our office knows first-hand since we have fought over 350 denials of cervical ADR all over the U.S., nearly all of those denials based on the insurer contention that the procedure is “experimental, investigational or unproven.”

That is just a couple of examples. Anyone reading this can cite many more examples impacting patient access to care in all areas of medicine.

So the critical question is “How do patients and providers effectively challenge these unreasonable bars to treatment access?” Not letting them get away with it without a fight is easy to say, but the simple premise of being “as mad as Hell” and not taking it anymore isn’t executed as frequently or effectively as it could be. I know from experience that there are many reasons this payer-dominance is the existing reality. Patients become resigned to being under the control of the monolith insurer; well-intentioned practitioners are often unable to help because of limited time or resources; those who are willing often don’t know what to do.

Being Mad or saying No to No is nice as a start. But it is only that – a start. Offering specific suggestions, strategies and tools to help those who are truly interested in improving meaningful access to appropriate patient care, even if it is “new” or “innovative” or “disruptive technology” will be the focus of PART 2 of “Can’t We Just Say ‘NO’ To No?!?”

So stay tuned and feel free to submit your comments . . .

Especially if you really ARE a rocket scientist!

Be Well

The Regence Group (which includes several Blue Cross Blue Shield affiliates in the states of Washington, Oregon, Idaho and Utah) has recently made 2 changes to their bariatric surgery medical policy no. 58 in the last couple of months.  Effective September 1, 2012, Regence (FINALLY!) included Sleeve Gastrectomy as one of its approved procedures.  Interestingly, it only approves the sleeve as a standalone surgery, but not as a “staged” procedure.

On the heels of that change, effective November 1st, Regence again revised its medical policy to eliminate one of the criteria elements in their pre-surgery diet criteria.  Regence required a patient lose weight or not gain weight during their “mandated” pre-surgical weight loss regimen.  It was a severe impediment for many patients.  That criteria was eliminated so if you are a patient (or treat a patient) who was denied by Regence because they did not lose weight during their pre-op diet you should IMMEDIATELY either (a) appeal that denial (if there is still time) or (b) resubmit a pre-authorization request to take advantage of this liberalization.

To review the updated Regence Group policy, click on this link:  Regence Group Bariatric Surgery Medical Policy

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Fishing For A Cure For A Terrible Disease -
Could This News Be More Than A Nibble?

BCBS Technology Evaluation Center (TEC) Has Groundbreaking Assessment
“In Press”

November 14, 2012 is “World Diabetes Day” so I cannot think of a better day to make people aware of news that appears to be coming very soon.  Pending final editorial re-writing, the Blue Cross Blue Shield Technology Evaluation Center appears poised to “endorse” the concept of gastric bypass surgery as a treatment for type 2 diabetes in people who are not morbidly obese.  The ramifications are, in my mind, monumental and could lead the way to more diabetics, including those suffering from morbid obesity, getting access to RNY for their diabetes.  At least it bodes well for the future and it is well worth watching for the final publication.  Of course I will alert you when that it available.

I first became aware of the idea of bariatric surgery as a possible treatment for Type 2 Diabetes shortly after I started this practice in 1996 when I read a medical journal article provocatively entitled “Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.”  (Annals of Surgery 1995;222:339-350)  The lead author was the esteemed Dr. Walter Pories, proving once again that all the coolest guys are named “Walter.”  The operation Dr. Pories and his colleagues were talking about was the RNY gastric bypass, the operation I had in 1994.  Since that time there have been tons of research dedicated to treating type 2 diabetes with metabolic surgery like gastric bypass.  The research done and the powerful data accumulated showing the potentially curative effects of various forms of weight loss surgery on type 2 diabetes eventually even led to the re-naming of a medical society, recognizing that its members (including yours truly since 1996) do far more than “weight loss surgery.”  They became the American Society of METABOLIC and Bariatric Surgery (ASMBS).

So what does any of this have to do with the title of this Blog post?  At the risk of sounding like the History major I was in college (along with Philosophy – no wonder I had to go to law school!) it is difficult to appreciate the present or map out the future without understanding the past.  It appears that we are on the verge of having an important arm of the National Blue Cross Blue Shield Association, the “umbrella organization” if you will, for all the local “Blues” that so often give patients and providers the blues, recognize that gastric bypass surgery is an effective treatment of type 2 diabetes for persons who are not morbidly obese, meaning people with diabetes (type 2) who have a BMI over 30.  You can go online and read the Executive Summary of Bariatric Surgery in Patients with Diabetes and Body Mass Index Less than 35 kg/m2 .  Certainly it provides our office and health care providers with more ammunition to fight against denials of care, whether for reasons of “medical necessity” or even in the face of contract exclusions or limitations for “obesity” or “morbid obesity.”

Let us hope this, along with newer and better medications and other non-surgical therapy, eventually leads to the end of this insidious disease that ravages our population and economically crushes our health care system.  Perhaps it will lead to the end of needing a “World Diabetes Day.” 

There’s always hope!

In its November 2012 “Medical Policy Update Bulletin” UHC announced their Coverage Determination Guidelines for Bariatric Surgery are being revised effective December 1, 2012.  You can access the full new Coverage Rationale at www.unitedhealthcareonline.com.  Once you are on that site open the pdf file entitled “2012 Network Bulletin” and scroll to page 6 of that document to see the summary.

The summary of changes they describe in the Bulletin include:

• Updated description of services to reflect most current clinical evidence and references and references

• Revised coverage rationale; added language to indicate vagus nerve blocking (VNB) or vagal blocking therapy is unproven for treatment of obesity

• Updated list of applicable (unproven) CPT codes; added 0312T, 0313T, 0314T, 0315T, 0316T and 0317T effective 01/01/2013

Until the actual Guidelines are published by UHC (on December 1st) it is difficult to tell if these revisions help or hurt patient access.  I haven’t had the chance (yet!) to do a line-by-line comparison with the current medical policy.  However since UHC is such a major player in the U.S. payer system this change may impact thousands of patients who are waiting to have their surgery and believe that it is covered based on existing criteria which is going to change in just a few weeks.

So if you’re a patient who has UHC you definitely want to keep your eyes on this change.  Similarly, if you are a bariatric provider who treats UHC patients, you should IMMEDIATELY contact your UHC Provider Relations representative to determine how this change impacts your UHC patients who are already approved under the old (July 1, 2012) medical policy.

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“Please understand that we are your health insurance plan – - we have special training in providing misinformation, acting incompetently, being argumentative and showing a complete lack of compassion or interest in your health.
Now having said that . . . . . .How Can I Not Help You Today?”

3 Reasons to Think Twice When Being Told ANYTHING By An Insurance Company

The ghouls and goblins don’t just knock on your door tonight yelling “Trick Or Treat”!  They sometimes reside in the so-called “Customer Service” departments of health insurers, proving on a daily basis that they are not interested in their Customers, nor usually capable of providing Service.  We thought some of these stories, and we have oodles of them, made for an appropriately ghastly Halloween blog.  Make sure you read all the way to the end so you can see what the Devil has in store for some of these folks in the insurance industry!

 So as I wish everyone a safe and happy Halloween, I offer special greetings (and a bit of a warning) to insurance company executives and their customer service representatives who seemingly delight in making patients and providers miserable on far too many occasions and I urge them to stop now. 

I was part of the Obesity Action Coalition’s Inaugural Member Conference in Dallas last week and had a wonderful time, including at the Halloween Costume Party.  It was there where I took on a role some say is quite natural for me, and for the occasion I created a special button to wear to clearly carry the message and warning of things to come for those in the insurance industry who do not change their ways. . . hopefully they listen! 

HAPPY HALLOWEEN!!

Remember the classic Seinfeld character “The Soup Nazi”?  If you didn’t follow his rules you’d get thrown out of line – - “No Soup For YOU”.  Some payers seem to take the same approach when it comes to requests for revisions or conversions of a prior weight loss surgery.  Instead of yelling “No Soup For You” they tell you something like “ONLY ONE SURGERY PER LIFETIME NOW GO AWAY!”  You shouldn’t go away….here’s a quick case study of a woman who demanded her “soup.”

This 51 year old woman asked us to help her get a revision from an adjustable gastric band to a RNY gastric bypass.  At 5’5″ and 359 lbs. and a BMI of 59.9 it’s hard to believe this insurer, based in Michigan, would deny her this procedure . . . OK – so it’s not so hard to believe – after all this IS an insurance company we’re talking about, right?

While she initially was successful with her band after she got it in 2005, and despite she had presented the insurer with several hundred pages of records showing that she was “compliant” with her post-operative treatment plan and tried very hard to get properly adjusted, it became clear she was unable to tolerate the band and she suffered from dysphagia (difficulty with swallowing) and maladaptive eating patterns.  That meant she, like many patients with all types of restrictive procedures (adjustable gastric bands, vertical banded gastroplasties, sleeve gastrectomies, etc.), resorted to a diet of soft, high calorie foods and liquids. Complicating her situation was the fact she suffered from an acoustic tumor which was going to require intercranial surgery . . . a surgery her doctors were not going to perform until she lost substantial weight.

1-877-99-APPEAL

It was nearly too late when she retained our office because she had nearly exhausted her appeals with the payer.  The were denying surgery for reasons all too many patients confront, plan language limiting the member to  one bariatric surgery per lifetime:

“… A member Shall only have one Baratric surgical procedure per lifetime unless medically necessary complication to correct or reverse a previous bariatric procedure from complications”

And before you read that language again and think “Geez he must have typed that wrong because that language doesn’t make any sense” I can assure you that is EXACTLY what the policy said.

There are many challenges in cases like these.  Can it really be established that there IS a “complication” even when there is no erosion, slip, obstruction, stricture or other identifiable “technical defect” in the original gastric banding procedure?  Shouldn’t this be challenged based on simple “fairness”?  After all, insurers don’t limit members to one cancer treatment – one knee replacement surgery – one diabetes medication, do they? 

ISN’T THIS PLAIN OLD DISCRIMINATION?????

Well the answer to these questions is YES and so we filed an IRO request as allowed by the plan and Michigan law. (Click Here To Learn More About The IRO Process)  We researched the data, got some important input from her neurosurgeon, put together a package and demanded the IRO be done on an expedited basis because of the emergent condition of her tumor.  Within 7 days of our filing the request an independent reviewing physician specializing in bariatric practice, including revisional surgery (which is not done by all weight loss surgeons), concluded that the removal of the existing gastric band and conversion to a RNY is consistent with the standards of good medical practice, is accepted and appropriate for her dysphagia and refractory morbid obesity, and is known to be effective for her condition.  He/she found this was a complication of the original surgery and required the plan to cover her revision notwithstanding the “one surgery per lifetime” exclusion.