Feeling really discouraged

[MegMac86]

Ive shared before but ill briefly explain that I have been having some troubles due to three separate hernias. I was referred to a general surgeon to get the umbilical and abdominal hernias fixed and was supposed to get the hiatal hernia worked on separately. I do not want to have to do two surgeries if it can be avoided so despite the abdominal hernia causing severe pain 1-2 times per week I postponed that surgery. Well today was my endoscopy and with it seems to have gone my hope that I would get to meet with a bariatric surgeon to troubleshoot it as they have decided the hiatal hernia isnt problematic enough to require surgery. In fact the doctors exact words were "you just need to lose weight and eat less". ARRGGHHH!! I already eat very little since my sleeve surgery (but of course they dont care). Anyways I called Dr. Keshishian's office thinking maybe I can get my primary care doctor to refer me to him but his office said that Blue Shield is now considered "Out of Network" for them. I cant self-pay (my student loans are horrendous so taking on another huge loan is out of the question). It is such a shame that we have so limited choices for DS doctors. Why is this?

I hate medical insurance rules so much!!! Best of luck as you navigate the maze. ❤️

 

[MegMac86]

You go, girl!

 

[DSRIGGS]

Again I am not sure what the difference is in our polivies but Kristina verified that nothing has changed on their end and they are still in network for BCBS. My procedure for next Thursday has bed approved. This will be my 3rd surgery for myself with Dr K and my oldest son also had a gastroparesis and Nissen fundoplication repair with Dr K.

I would call BCBS directly and ask them why Dr K would be considered out of Network for you when he is in network for my BCBS PPO.

I am sorry for your struggles.

What about Rabkin in the bay area? Have you tried to see if he is in network? He is also an excellent DS Surgeon.

 

[southernlady]

Okay, BCBS...each state or group of states have different rules. BCBSTN (my old plan) is NOT the same company as BCBSNC even tho both were medicare plans and BOTH were PPO's. Yes, they all carry the name BCBS but other than that, they do NOT coexist. One time I asked why not, was told that is just the way it is.

@HereIGoAgain is yours an HMO, a PPO, or a REGIONAL PPO? Which BCBS company is it?
@DSRIGGS (Scott), yours is a PPO but which BCBS company is it issued under?

The answers may explain the difference.

https://en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Association

The Blue Cross Blue Shield Association (BCBSA) is a federation of 36 separate United States health insurance organizations and companies,

Blue Cross and Blue Shield insurance companies are licensees, independent of the association and traditionally of each other, offering insurance plans within defined regions under one or both of the association's brands. Blue Cross Blue Shield insurers offer some form of health insurance coverage in every U.S. state. They also act as administrators of Medicare in many states or regions of the US[12] and provide coverage to state government employees as well as to the federal government employees under a nationwide option of the Federal Employees Health Benefit Plan


Member companies
Publicly traded companies

• Anthem Inc
  • Anthem BlueCross and BlueShield[15]
    • Colorado
    • Connecticut
    • Georgia
    • Indiana
    • Kentucky
    • Maine
    • Missouri (excluding 30 counties in the Kansas City area)
    • Nevada
    • New Hampshire
    • Ohio
    • Virginia (excluding the Northern Virginia suburbs of Washington, D.C.)
    • Wisconsin
  • Anthem Blue Cross (California)[15]
  • Blue Cross Blue Shield of Georgia[15]
  • Empire BlueCross BlueShield (New York)[15]
• Triple-S Management Corporation (BlueCross & BlueShield Puerto Rico)

Multi-state private companies

• CareFirst
  • District of Columbia
  • Maryland
  • Parts of Virginia
• Health Care Service Corporation
  • BlueCross BlueShield of Illinois
  • BlueShield of New Mexico
  • Blue Cross Blue Shield of Montana
  • BlueCross BlueShield of Oklahoma
  • BlueCross BlueShield of Texas
• Highmark
  • Highmark BlueCross BlueShield (Western Pennsylvania)
  • Highmark BlueShield (Northeastern, Eastern & Central Pennsylvania)
  • Highmark BlueCross Blue Shield Delaware (Delaware)
  • Highmark BlueCross BlueShield West Virginia (formerly Mountain State Blue Cross Blue Shield) (West Virginia)
• Premera
  • Premera BlueCross BlueShield of Alaska
  • Premera BlueCross (Washington)
• Cambia Health Solutions
  • Regence BlueShield of Idaho
  • Regence Blue Cross Blue Shield of Oregon
  • Regence BlueCross BlueShield of Utah
  • Regence BlueShield (Washington)
• Wellmark Blue Cross Blue Shield
  • Iowa
  • South Dakota

Single-state or regional companies

• Blue Cross and Blue Shield of Alabama
• BlueCross BlueShield of Arizona
• Arkansas BlueCross BlueShield
• Blue Shield of California
• BlueCross BlueShield of Florida (branded as Florida Blue)[16]
• Hawaii Medical Service Association
• BlueCross of Idaho
• BlueCross BlueShield of Kansas
• BlueCross BlueShield of Louisiana
• Blue Cross Blue Shield of Massachusetts
• Blue Cross Blue Shield of Michigan
• Blue Cross Blue Shield of Minnesota
• Blue Cross Blue Shield of Mississippi
• Blue Cross and Blue Shield of Kansas City
• Blue Cross Blue Shield of Nebraska
• Horizon Blue Cross Blue Shield of New Jersey
• Excellus BlueCross BlueShield (Central New York, Rochester and Utica/Watertown)
• BlueShield of Northeastern New York (A division of HealthNow New York Inc.)
• BlueCross BlueShield of Western New York (A division of HealthNow New York Inc.)
• Blue Cross Blue Shield of North Carolina
• Blue Cross Blue Shield of North Dakota
• Blue Cross of Northeastern Pennsylvania
• Capital Blue Cross (Central Pennsylvania)
• Independence Blue Cross (Philadelphia, Southeastern Pennsylvania)
• Blue Cross Blue Shield of Rhode Island
• Blue Cross Blue Shield of South Carolina
• BlueCross BlueShield of Tennessee
• BlueCross BlueShield of the U.S. Virgin Islands
• BlueCross BlueShield of Vermont
• BlueCross BlueShield of Wyoming

 

[DSRIGGS]

Anthem BCBS is what we have.

I know each state has one BCBS office to whom Dr's submit claims so that is my confusion.

 

[k9ophile]

I appreciate the info about BCBS, so I won't repeat it. I'd like to add that even within each state the coverage is not identical. If it is paid for (even partially) by an employer, there can be differences that won't be covered. When I worked for a catholic hospital I had Cigna or BCBS (can't remember) that would not pay for anything related to birth control. Therefore it is necessary to have your policy coverage and limitations.

As for in-network vs out-of-network, doesn't that apply to which doctors agree to cooperate with the insurance company's Conditions of Participation? I did have an incident where one physician did not participate even though the others in the group did. I think as much of a nightmare it is for patients, it is also chaos for medical practices to keep up with what is covered by which plan.

 

[CaraOC]

You are in CA - which DS surgeons are in-network for you? Because if there is no qualified in-network surgeon (keeping in mind your reasonable desire to have ALL of these problems fixed at once), then your insurance almost certainly has to pay for you to go to a qualified out-of-network surgeon.

If your plan is an HMO, even better, because there will NOT be a qualified surgeon in-network, and Larra and I have helped people with this situation before.

What you have to do is to request your PCP to refer you to Keshishian as a covered out-of-network referral, because there is nobody in-network who can deal with your medical situation in one surgery, and you want ONE surgery. S/he will say no, or she will make the request to the HMO managed care for the out-of-network referral, and you will in either case get a denial, vesting your appeal rights.

Then, while we help you appeal the denial, you will self-pay for a consult with Dr.K, who we hope can write you an LOMN that says you need the switch, and that he can also repair your umbilical, abdominal and hiatal hernias at the same time. It is more likely than not that the DMHC will overturn the plan's denial. And you should get reimbursed for the cost of the consult

That's how to handle it from an insurance perspective.

However, depending on how much of a problem the abdominal and umbilical hernias are, I would like to point out another set of considerations.

• You are still MO, I assume.
• If you get the abdominal and umbilical hernias fixed NOW, you are not going to have as good a cosmetic result as you would if you could wait until after you lose more weight after getting the switch.
• In fact, if you can wait, it is possible that you could get them fixed AND get a proper abdominoplasty covered by insurance (again with help from me and Larra - I got my husband an abdominoplasty to avoid the use of mesh to repair his umbilical hernia, and he got a bit of a FUPA lift as a bonus).
• Similarly, it is possible that your surgeon is right and that you might not need a hiatal hernia repair after you lose more weight - and a hiatal hernia repair after having a sleeve is more difficult, because there is no fundus to make the Nissen fundoplication wrap (@Larra, do I have that right?). But that is something to ask Dr.K.

@DianaCox i just saw my surgeon today and he tells me I need a mesh abdom hernia repair. He said I could consult with a plastics person to coordinate either the abdominoplasty or panectulectomy at the same time. He only did A finger squeezing exam. How can a diagnosis of DR be made?? I want a once under the knife deal. I want the whole shabang. Wash board abdomen that quarters can be bounced off of. Please please point me in the right direction!! Help me take those bastards at CIGNA by a handful of the short and curlies!! I know they won't pay a dime unless I scream and shout.

 

[Larra]

Abdominal wall hernias can usually (not always!) be diagnosed on physical exam without any other diagnostic tests. The exact extent of the hernia may not be evident, meaning it might be worse than what you can tell from the outside, but then again, even tests like CT scans and such don't always get it right either. As to whether or not mesh is needed it often is with an incisional hernia (most likely what you have), but then again, there are also some surgeons who routinely put in mesh and others who try harder to use your own tissues. So you might consider getting a second opinion from another general surgeon. That doesn't help you with the insurance issue, but might give you a little peace of mind that you really do need the hernia fixed one way or another.

 

[DianaCox]

1) Consider finding another surgeon
2) Consider doing a consult with an in-network reconstructive surgeon first, to get the diagnosis of (incisional? umbilical?) hernia, complicated by diastasis recti, along with a recommendation that an abdominoplasty (with or without component separation? at least with muscle plication) would provide a more durable result, without the possible complications from mesh, and ask if s/he would be willing to work with a general surgeon (and if so, whom s/he would prefer).
3) Submit to insurance company with well-crafted letter of medical necessity recommending the abdominoplasty, in order to avoid mesh (try to give a good reason why - with my husband, it was because he had problems with a prior mesh inguinal hernia repair).
4) Make sure that the reconstructive surgeon agrees that in coding for a MEDICALLY NECESSARY abdominoplasty, the codes in fact actually also cover lipectomy and skin excision):

From a reconstructive surgery policy I found online which sets out the Medicare guidelines:

"Medicare considers excision of excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would affect the healing of the surgical incision."
​

Make sure the letter of medical necessity follows this language.

 

[CaraOC]

1) Consider finding another surgeon
2) Consider doing a consult with an in-network reconstructive surgeon first, to get the diagnosis of (incisional? umbilical?) hernia, complicated by diastasis recti, along with a recommendation that an abdominoplasty (with or without component separation? at least with muscle plication) would provide a more durable result, without the possible complications from mesh, and ask if s/he would be willing to work with a general surgeon (and if so, whom s/he would prefer).
3) Submit to insurance company with well-crafted letter of medical necessity recommending the abdominoplasty, in order to avoid mesh (try to give a good reason why - with my husband, it was because he had problems with a prior mesh inguinal hernia repair).
4) Make sure that the reconstructive surgeon agrees that in coding for a MEDICALLY NECESSARY abdominoplasty, the codes in fact actually also cover lipectomy and skin excision):

From a reconstructive surgery policy I found online which sets out the Medicare guidelines:

"Medicare considers excision of excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would affect the healing of the surgical incision."
​

Make sure the letter of medical necessity follows this language.

So this general surgeon gave me cards to two plastic docs he frequently does work with. So I should set up an appointment with them then?? This may help, I have a VP shunt and I've had multiple abdominal revision surgeries because of displacement. This might strengthen the case. Thank you thank you thank you for all your amazing knowledgeable advice. I so do not want multiple trips under the knife.

 

[DianaCox]

Yes - but don't limit your search to PS surgeons your general surgeon recommends.

 

[Munchkin]

Just don't give up. Be persistent, the squeaky wheel.