Employer self paying insurance plan

[KYSassy]

What is the name of your state? Kentucky.

My health insurance is through a company self paid plan with a third-party administrator. On January 1, 2003 it changed to
Anthem BC/BS(still third-party adminstrator). I was pre-certified for gastric bypass surgery. I'm going through the testing phase to determine my suitbility for the surgery and I was told that I meet the criteria for the procedure and probably be scheduled for surgery in March. Now, the insurance co. is saying that any treatment for weight loss is an exclusion. That is not true because the prescription part says that weight loss drugs are not covered "except for morbid obesity". It also says the employer may cover services not allowed at its own descrection. Can they be forced to follow through on something they approved under the other policy or can they hide behind the new third party's administration of guidlines knowing very well I am in the middle of this treatment they were previously paying for?

 

[ellencee]

KYSassy
My answer is based on what happened when my husband's employer, also providing a self-insured insurance plan with a third party administrator, changed to BC/BS--they denied so much to so many, the company booted them after 3 months and went back to the previous third party administrator. So, I guess they can deny you coverage for the surgery inspite of what was approved by the previous third party administrator.

Get your physician involved and ask him, or her, to write a letter of medical necessity, listing the physical problems the weight is causing and the risk associated with not having the surgery and the cost of treating these problems as opposed to the cost of the surgery to eliminate these problems.

 

[lkc15507]

I hope you will pardon me if I am a little thick here, but I'm not positive I understood the exact change in the insurance plan. But, I will attempt to answer in either case.

If what I think I understand is correct, that your self-funded plan simply changed TPA's, the original insurance coverage provided in the plan probably did not change. (It is possible though that benefits offered did change. Check with the employer!) It is very common for different TPA's to interpret plan benefits differently. But, remember, with a self-funded plan, the TPA simply administers the plan as written. A change in TPA does not mean the benefits changed. In a situation such as this, the TPA that will ultimately pay the claim has the fiduciary responsibility to administer the plan according to the intent of the plan as written. They may not agree with the previous TPA's determination of eligibility for benefits. Given all of that, the new TPA can deny the benefits based on their interpretation of the plan. But, it is the insurance plan as written by the employer, not the TPA, that ultimately determines if a service is covered. My point here is that the insurance plan should be clear to either TPA. If not, any ambiguity in the plan language usually results in the favor of the insured when legally challenged. Read all sections of the applicable plan document, including definition of morbid obesity, plan exclusions, and the medical benefits section. A common definition of morbid obesity is a body mass index (BMI) of greater than 40. There may also be provisions that the obesity must be contributing to / complicating another medical condition such as heart disease. BMI charts may be found easily on the internet. The plan will also include an appeals procedure. Have your physician submit a letter of medical necessity. In addition, include the determination of the previous TPA as support. If the new TPA still denies coverage that you believe to be eligible, then you can appeal the decision to the employer plan itself.

Now, if I totally misunderstand your situation and the plan actually changed from a self-funded plan to a fully insured plan, then the new insurer is not bound at all by the previous self-funded plan or any determination that the TPA made on behalf of that plan.

The best course of action is to obtain a current plan document for the available coverage and read all sections carefully. Your employer's human resourses department should provide this to you upon request (if you don't already have a current one) and help you to interpret the plan. Then, use your physician to document the medical necessity of the procedure for which you are requesting coverage. Supply medical records. Also, with surgery scheduled in March, do not delay in gathering and submitting your information.

I hope this was not too confusing. Please take care and read your plan document carefully.

lkc15507