Posted this in legal advice and medical_advice, was told to post here.
Here’s a timeline of events. I’m in CA
I have an abnormal growth (chest related). My primary care provider documented it as a possible deformity, they referred me in network to an oncologist, who then referred me to an in network surgeon. Receptionist told me to explain the reason for visit, stated I wanted a reduction and/or implants, she said the reduction could possibly be covered by my insurance, implants will probs be seen as cosmetic, I agreed and told her I understood and wanted to at least get the reduction. Go to consultation, they take my copay, doctor and I go over the issue and how I was referred to him bc of my insurance, gave me a synopsis of he procedure he said would work best. The person who makes the financial quote document wasnt in so I had to wait about a week to see the quote. I asked if it would be sent to my insurance, they, they dont take any insurance. Under guidelines I was confused why nothing would be sent so I filed an appeal because I received neither an approval OR denial. My insurance said it wasnt considered reconstructive and thus not a medical necessity. I was advised by a customer service provided to reach out to California Department fo Healthcare Management, who then sent my case to the Maximus Federal Services in which the decision overruled my insurances decision and ruled in my favor that this is a medical necessity and that my insurance had to approve the services. I recieved the letter that it had been approved and that I was now able to schedule a consultation with the surgeon to then schedule the surgery, but when I called to make the appointment, the receptionist rejected my efforts and said “that’s incorrect, we dont take insurance, you need to see a different surgeon” and wouldnt allow me to make an appointment. I was on the phone for hours trying to find out what is happening, apparently the surgeon does take insurance, but not for the procedure that I have been approved for. Maximus defined the decision and “final and binding”. Can anyone help me out in understanding what’s going on and why this surgeon who is contracted in my network won’t take this further? I’m already seeing about getting a second opinion, but wouldnt that jsut overrule what was already deemed approved?
submitted by /u/throwawayyyyyyymed
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Posted this in legal advice and medical_advice, was told to post here. Here’s a timeline of events. I’m in CA I have an abnormal growth (chest related). My primary care provider documented it as a possible deformity, they referred me in network to an oncologist, who then referred me to an in network surgeon. Receptionist told me to explain the reason for visit, stated I wanted a reduction and/or implants, she said the reduction could possibly be covered by my insurance, implants will probs be seen as cosmetic, I agreed and told her I understood and wanted to at least get the reduction. Go to consultation, they take my copay, doctor and I go over the issue and how I was referred to him bc of my insurance, gave me a synopsis of he procedure he said would work best. The person who makes the financial quote document wasnt in so I had to wait about a week to see the quote. I asked if it would be sent to my insurance, they, they dont take any insurance. Under guidelines I was confused why nothing would be sent so I filed an appeal because I received neither an approval OR denial. My insurance said it wasnt considered reconstructive and thus not a medical necessity. I was advised by a customer service provided to reach out to California Department fo Healthcare Management, who then sent my case to the Maximus Federal Services in which the decision overruled my insurances decision and ruled in my favor that this is a medical necessity and that my insurance had to approve the services. I recieved the letter that it had been approved and that I was now able to schedule a consultation with the surgeon to then schedule the surgery, but when I called to make the appointment, the receptionist rejected my efforts and said “that’s incorrect, we dont take insurance, you need to see a different surgeon” and wouldnt allow me to make an appointment. I was on the phone for hours trying to find out what is happening, apparently the surgeon does take insurance, but not for the procedure that I have been approved for. Maximus defined the decision and “final and binding”. Can anyone help me out in understanding what’s going on and why this surgeon who is contracted in my network won’t take this further? I’m already seeing about getting a second opinion, but wouldnt that jsut overrule what was already deemed approved?
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