I was scheduled to have skin removed in a fleur de lis tummy tuck on the 24th of February, unfortunately my insurance company denied, and my surgeons office said I'd have to wait 6 months to appeal . I thought that was a bit long to wait just to come up with the same documentation on this skin causing problems. Apparently the plastic surgeon won't do peer to peer and I'm confused as to why . If that's all the insurance company wants shouldn't he do it
February 17, 2017
Answer: Insurance denial and appeal process Thank you for your questions - often when an insurance company denies coverage of a procedure, they provide a list of reasons. If these reasons include prerequisites that you have not fulfilled (documentation of conservative management from your primary care for a certain duration of time for example, or a certain number of episodes of infection/cellulitis which required antibiotics), then having a peer-to-peer phone call will not help. The only time a peer-to-peer is useful is when you have demonstrated compliance with all listed prerequisites and requirements and the insurance company is still denying pre-authorization. I suggest calling your surgeon's office to understand what additional information is required so that you can ensure that is complete before resubmission. Best of luck!
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February 17, 2017
Answer: Insurance denial and appeal process Thank you for your questions - often when an insurance company denies coverage of a procedure, they provide a list of reasons. If these reasons include prerequisites that you have not fulfilled (documentation of conservative management from your primary care for a certain duration of time for example, or a certain number of episodes of infection/cellulitis which required antibiotics), then having a peer-to-peer phone call will not help. The only time a peer-to-peer is useful is when you have demonstrated compliance with all listed prerequisites and requirements and the insurance company is still denying pre-authorization. I suggest calling your surgeon's office to understand what additional information is required so that you can ensure that is complete before resubmission. Best of luck!
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February 17, 2017
Answer: Peer to peer review If the insurance company referenced a mandatory prerequisite that you have not fulfilled, there would be no reason to go through the peer to peer review. If they require 6 months of documented dermatology treatment, for example, then if you want to have surgery now, it would be fee for service. If you are willing to wait and try to comply with the criteria, then start the conservative management and reschedule the procedure. Also, you should have received a copy of the denial letter containing appeal rights. Read it because appeals are typically required within 30 days, not after 6 months.
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February 17, 2017
Answer: Peer to peer review If the insurance company referenced a mandatory prerequisite that you have not fulfilled, there would be no reason to go through the peer to peer review. If they require 6 months of documented dermatology treatment, for example, then if you want to have surgery now, it would be fee for service. If you are willing to wait and try to comply with the criteria, then start the conservative management and reschedule the procedure. Also, you should have received a copy of the denial letter containing appeal rights. Read it because appeals are typically required within 30 days, not after 6 months.
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