Should I switch insurance companies?

[drakenheart26]

I was supposed to have oral surgery over winter break sometime near Christmas. Unfortunately my surgeon's office didn't send in the pre-authorization fast enough so we ran into some problems with insurance and didn't have time to fix them before the surgery date.

My insurance is anthem blues shield blue cross and they denied my surgery, although they denied it in a very unprofessional way. The first denial literally dropped the sentence off right before stating the reason for denial giving me no clear reason for denial. The second time my surgeon's office sent in the pre-authorization with more information anthem sent back a denial with the wrong measurements. I know that I need oral surgery, I have an open bite that is causing problems, and the best long term option is to have surgery and I've been told/reassured this by multiple surgeons and orthodontists. I looked at the medical policy that anthem was basing the denial on and I clearly fall under the medical necessity requirements which pisses me off a lot that they would be so unprofessional about this.

Anyways, I've been waiting for about a month now to let my surgeon's office work this whole situation out. We did run into other problems, my surgeon is not in-network, but the facility he works at is so they were trying to get him in-network with anthem. My surgeon's office doesn't contact me with a lot of information about what is happening and I'm starting to get to the point of frustration where I just want to say "screw it all" switch insurance companies and start over with a new surgeon and hopefully have my surgery done next winter.

So my question is this: If I were to switch from Anthem to Kaiser would it be worth it? If anyone here has had their surgery covered by either of these insurances please tell me your story of how you had your surgery covered. I know that this surgery is not easy to have covered, but Anthem has been really ridiculous with this and I just want to know if the process would be easier with Kaiser since I've heard their typically better with this.

Any help is very appreciated, this whole ordeal has been very draining emotionally I'm willing to wait for my surgeon's office a little longer, but if my insurance keeps denying the pre-authorization this could easily take up to two years with appeals and what not.

[Lala082008]

I'm sorry about your experience, that sounds very frustrating! I don't have any specific knowledge about your insurance company, but I will tell you what my surgeon told me at my consult.

My surgeon - who is highly experienced - said the insurance companies will pretty much always deny your claim at first. He said typically multiple levels of appeal are required. He even mentioned that I might have to write a letter to the board of insurance commissioners in my state to get them to require my insurance company to pay for the surgery. I get the impression that this is the norm, as he said his office begins the preapproval 6 months prior to the anticipated surgery date to allow for all of this to happen.

So all that to say, I'm not sure switching insurance companies would solve anything. Have you tried asking your surgeon's office what the typical time period is to get the final approval and if they think your insurance company is acting slower than would be expected?

[snapdresser]

If you meet the requirements for medical necessity, you shouldn't be having an issue getting it approved and I'm a little surprised to hear that you are. I got mine through Empire BCBS on the first try with no issues. Are you sure it's not the surgeon messing up their application, sending incomplete documentation, etc.? Your surgeon said that insurance companies "pretty much always" deny your claim on the first try, but that's not true for in-network surgeons that send the proper documentation the first time. If you're having a huge issue getting your surgeon to be covered, you might consider finding an in-network BCBS surgeon like I did. I wouldn't drop Anthem BCBS though; they're one of the better ones in covering the surgery.

[drakenheart26]

Thank you very much for the replies, both of you. I am thinking that it may be the surgeon's office that is the issue. Like I said the surgeon I've been visiting is not in-network (although they were when I first looked them up so I don't know what happened), but the facility he works at is. I am also thinking that the insurance team may have messed up the pre-authorization and weren't technical enough or didn't supply enough information. Like I said they didn't act very quickly with getting the surgery pre-authorized, I found out that they literally sent it in about a week or two before the surgery.

I know that this surgery is hard to have covered I guess I've just been shocked with how unprofessional these "professionals" have been treating my case. I'm glad to hear that you guys think it would be better to simply stay with my current insurance since I wasn't really looking forward to switching insurance companies just for this surgery. Now that I've written my case out and had some feedback I am thinking that my surgeon's office's insurance team is probably the underlying problem for this whole ordeal. I will look definitely be meeting with another surgeon that is in-network for sure, and speak with them about their process of having the surgery pre-approved right away and hopefully have everything ready to go for next winter.

[drakenheart26]

Sorry about the double post, but I got a call today from my surgeon's office and they said that they were able to work with the insurance and my surgery is now authorized! =D I am so glad that I didn't have to appeal or switch surgeons or insurances or anything like that. Most of all I am so excited that I can finally have my bite fixed! Thanks again for the feedback guys!

[Lala082008]

Congrats!!!

[snapdresser]

Congrats, drakenheart26!!!

[sirwired]

I know my surgeon's "insurance person" apparently forgot to include my measurements with my initial submission. Luckily, I got the phone call about the denial from Anthem while I was literally walking back to my car from a pre-surgical appointment, so I turned right around, marched into the dental school building, and camped outside the insurance person's office until she got off the phone, and had her listen to her messages and get the right info faxed over.

Once she did that, Anthem approved me in under two weeks.