Just waiting and trying to figure out what to do if my request to go out of network is denied
The request has been submitted to go out of network for my my DS. I don't have a good feeling about this because I think that insurance will view it as more of asking for a second opinion because all I have in writing is that Dr Lalor doesn't think I am a good candidate the DS and recommends an RNY. . As I said he is the only one in my insurance's network that has ever actually done a DS. I did put in there that is has actually only ever done 4- so I hope that helps. I don't have any proof of that of course. That's just what he told me. It was explained in the letter that Dr Kemmeter has much more experience and if he says that RNY is still my best bet, I will have it done here, but all of my reasons are listed for thinking that the DS will be the best one for me. My PCP was awesome enough to let me write the letter like she was writing it, and then she signed it and sent it.
I am on the fence about what to do if my request to see Dr Kemmeter is denied. I don't have any experience with appeals. I could do the appeal or I could fork out the case to have Lindstrom Obesity Advocates do it. I hear a lot of great things about them. I did ask around. It sounds like it is about $1,000 to get them involved. I know that this doesn't sound like a lot but I've already spent a lot of money on pre-op stuff with Dr Lalor, plus if I win the appeal I'd have to come up with another $750 for the program fee for Dr Kemmeters office. I don't really want to deplete my emergency fund. I realize its not a HUGE amount of money but it kind of is for us. My husband is only working part time.
My question is, have any of you appealed an out of network decision? Is it something that I could do on my own and be successful with? Or is it a difficult process to do that I would need a pro to win?
Ironically I got a call from Lalor's office that my RNY was approved. I said "You mean my DS?" She said she called and changed the procedure code to RNY when she found out that Dr Lalor wouldn't do it. I was at least looking forward to telling Dr Kemmeters office that there was no problem with insurance allowing the DS, although Dr Lalors office said it was covered by my insurance and wouldn't be an issue.
So far, Dr Kemmters office has been awesome. I just have to send my records with $250 for review. The coordinator talked to Dr Kemmeter and he said he would have no problem with doing the DS with my BMI being under 50 as long as he thought I was a good candidate and said he would do a phone consultation so I don't have to drive there. I'm not going to have to redo anything but I may have to do additional labs, etc. But, before that, I have to get the insurance stuff straightened out so I can go out of network. I really like their office and am going to be devastated if I can't make this work out.
Are there any insurance folks on this board who can give me tips?
I know that there is always someone on this board who has gone through the battle before me (whatever the current battle may be. LOL)
Sonya B, Toledo, Ohio- RNY 08/20/13
Sonya, there are a few people on here who have some good insurance appeal knowledge, that hopefully will be able to help you with this, if the situation arises. If you are denied, I would start a new thread with some wording related to appealing in your header. Kemmeter's office IS awesome, and I'm not just saying this because I'm biased - I've been through many other procedures through other practitioners as well. I am seeing him tomorrow morning for my two week post-abdominoplasty checkup. Are you on Facebook? There is a Michigan DS page there that consists of many of Dr. K's patients, as well as others from Ohio/Indiana. If you search for MIDS, you will find it. I will PM you my name, because you might need to friend me to join.
Good luck, I"m really rooting for you!
Duodenal Switch 08/09/06 - Dr. Paul Kemmeter, Grand Rapids, Michigan
HW: 282 - 5'4"
SW: 268
GW: 135
CW: 125
