Monday, March 03, 2008

Your Surgeries and Health Insurance

Having been absent from this blog awhile, I had not seen a comment here that deserves some attention. It had to do with health insurance and cosmetic procedures following surgery, in this person's case, a problem arising from casting. Many times the insurance company will try to tell you the scoliosis surgery itself is cosmetic. I love insurance. Heh heh. Michael Moore knows.

I, of course, am in no way able to guarantee your insurance company will pay for anything. I didn't find out until later (this was before I worked for an insurance company) that my doctor had to fight to get my son's surgery authorized, even though it was for medical reasons. The insurance company had wanted to kick it out as "cosmetic."

But since that time, I have worked for a large group health insurance call center for a couple of years, and I do have some suggestions. So here is my advice:

Cosmetic types of procedures, and those which have any possible way of being construed as such will be submitted to your health insurance company with certain codes that identify them. Chances are "autoadjudication" software will kick them out and deny them. To get such a procedure approved, you must send in, or your doctor send in, depending on your policy, complete medical records so that you can document that this problem arose from the surgery. Or, if it's the scoliosis surgery itself, that you require this surgery for medical reasons. Call your insurance company's pre-authorization department to find out exactly what they want.

Remember there's going to be a wait for preapproval on this type of surgery because although it may feel so to you, to the insurance company this is not a life and death situation and their volume of work is huge. If you wait a reasonable period of time, call. Make sure your records were scanned into their computer system. If you start hearing records weren't received, demand to speak to a manager or supervisor, get their name and FAX the records. If you still don't receive satisfaction, contact the Insurance Commissioner. This is the best advice I have.