Hi from Southern California

[BigBedRock]

Hi from Southern California!
I'm pretty excited about this. I now have health insurance that covers bariatric surgery!!

I first joined a different website for help with obesity years ago. Maybe 2007 or 2008. So long ago that I couldn't remember my user name or password and must have used my previous work email so I couldn't get logged in until it dawned on me to open a new account. I did that yesterday and Larra reached out to me and invited me to this web site.

Years ago I thought a wanted a gastric bypass. I never could afford to pay out of pocket so I could only read and learn and covet what other people had. During that time I also tried many other weight loss diets and lost and gained back lots of weight. The silver lining to that dark cloud of waiting is that I found out about the DS during that time and decided that if I ever could get bariatric surgery I would get the DS or nothing.

So now I have new insurance, it covers bariatric surgery and I'm coming here to ask for encouragement and guidance through this process.

My insurance is Aetna HMO. I'm in Southern California and I have been in contact with Dr. Keshishian's office.

I'm aware that my particular Aetna insurance (through my husband's employer) requires 6 months of medical diet (I hope to have enough documentation of my diets to cover that - fingers crossed.) I was told by the insurance customer service that a psych eval is required.

I have many questions on how to move through the insurance maze most expediently. I thought I was on top of it, but the process seems to be dragging out. I got a referral from my PCP and that office said that my insurance company would choose a surgeon for me. Eventually an authorization for a surgical consult was given for a surgeon at UCI - one who does not perform the DS.

At my request my PCP also submitted a referral for a sleep study, in case a co-morbidity is needed but I think maybe the osteoarthritis in my knees would also be a co-morbidity.

It seems to be such a waste of time to get a generic referral to someone in the Insurance companies "network" when noone in their "network" performs the surgery I will give informed consent for. I would like to learn how to avoid spending anymore time trying to get the referrals changed to the wrong surgeon to the correct surgeon (or psych). How does that work?

I have waited so long for this and it would be so great to be able to avoid spinning my wheels and instead get good enough traction on this process to have surgery before the end of the year.

Please forgive me for just jumping in here so boldly when you really don't know me - but I am now 56 years old and I don't want to needlessly waste another minute of my life away with obesity. I would be so grateful for any support and guidance anyone might offer whether professional experience, personal experience, links to pages where this has been previously discussed, anything at all!.

Thank you, Larra, and thank you to any others who may be able to offer guidance.

Betty

 

[Bagaof4]

Hi Betty and welcome to the board! I am also a Southern Californian, but have little to offer re insurance issues (I have Kaiser). Just wanted to welcome you and say you have come to the right place!

 

[BigBedRock]

Thanks Bagaof4 for your warm welcom

 

[Larra]

Hi again and welcome!

Would it be possible to talk to someone at the insurance company about not seeing the surgeon at UCI and going straight to Dr. K? And if the first (i.e. lowest level) person says no, requesting to speak with a supervisor? I find it very disturbing that your insurer can dictate who your surgeon is going to be. Check and see if Dr. K is in network and if so, insist on seeing him. And as soon as you get your hands on the EOC, check to make sure the DS is covered. It's great that you finally have coverage for bariatric surgery, but that doesn't guarantee that all standard of care operations are covered.

 

[Charris]

@Larra Dr. K only takes PPO's and original Medicare

 

[BigBedRock]

Hi Larra,
I, too, was uncomfortable with hearing that the HMO would choose the surgeon.

My previous PCP's practice was sold or bought out or something similar to that and there seems to be confusion among this new PCP's office staff about insurance and the referral process.

Yes, of course, I can ask the customer service person about this and then try to move that over that person's head if unsuccessful.

Do you think one approach is better than the other? Could I lose anything by trying both approaches?

Just hoping to find the most direct way through this and to stop wasting my time with circuitous unproductive approaches. I'll be specifically requesting the EOC.
Thanks for your advice and encouragement.
Betty

Hi again and welcome!

Would it be possible to talk to someone at the insurance company about not seeing the surgeon at UCI and going straight to Dr. K? And if the first (i.e. lowest level) person says no, requesting to speak with a supervisor? I find it very disturbing that your insurer can dictate who your surgeon is going to be. Check and see if Dr. K is in network and if so, insist on seeing him. And as soon as you get your hands on the EOC, check to make sure the DS is covered. It's great that you finally have coverage for bariatric surgery, but that doesn't guarantee that all standard of care operations are covered.

 

[JuliaDS]

Hi Betty and welcome! You'll find a wealth of solid information and support here.

I have Aetna HMO and had my DS 3 weeks ago with Dr. Bonanni in PA. Insurance has paid for everything (with the exception of a couple of $25 co-pays for some of the pre-op specialist testing) and I must say it's been easier than I expected! Everyone's specific plan is different so you'll need to find out the details of your plan, but mine required either 6 months documented diet or 3 months 'must-disciplanarey' program. The later turned out to be the surgeon's pre-op program which I needed to do anyway so I went with than option (3 visits w/nutritionist, 1 w/psych, 1 support group, tons of pre-op specialist testing, a pre-op class/exam, and detailed consult with the surgeon). One referral from my PCP covered everything.

Hope you're insurance experience goes smoothly. First step - get a copy of your specific plan then call Aetna to confirm everything. Good luck!

 

[duh_Mom]

Hi @BigBedRock and welcome! you are in the right place, and as far as I am concerned, you have chosen the correct surgery. I had lapland surgery many years ago because I did not want my guts rearranged - well, back then, i never heard of DS surgery. So, I muddled along and did not really lose weight. I finally decided to see a bariatric surgeon to see what my options were and found out about the DS. Personally, I think I had divine guidance because I went to a local surgeon who just happens to be a trusted DS surgeon. I did not do like you are doing and research on the internet until after I heard about the surgery.
The vets here will help you navigate the waters. Don't give up on your choice of a surgeon and what YOU need, not what the insurance company thinks you need.
I look forward to getting to know you and watching your journey.

 

[aaa]

Welcome.

 

[DSRIGGS]

Hi and welcome @BigBedRock .

I am a Dr K revision patient who was malabsorbing too much because my original surgeon didn't use the Hess method and my Alimentary Limb was too short. I traveled from the Peoria, IL area to have surgery with the best person and Bariatric surgeon you could ever have the pleasure of knowing. He is just awesome and so are his staff members (Kristina and Silva).

Do everything in your power to get to Dr K and I know Charris said he only takes PPO's and Medicare but I would check with his staff because things change in that regard all the time. Healthcare and insurance is a very fluid game with the rules changing all the time so definitely investigate and get to him.

If for some reason you aren't able to do surgery with Dr K (I hope you can) then make sure your surgeon employs the Hess Method for determining you AL, CC & BPL lengths (should be 40%, 10% and 50% respectively and those are guidelines but customized to the patient based on individual circumstances). Had I known to do this up front I would not have suffered the issues I have for the last 2 years (I would still do the DS again, regardless).

Good luck on getting in to Dr K and to joining us on the dark side!

 

[southernlady]

Welcome @BigBedRock

 

[Larra]

I think the first step is to get your EOC and make sure the Ds is covered. If it is, and there is no in-network surgeon who does it, you can request (politely demand) to be sent out of network because it's not your fault that their network doesn't include a surgeon who does a covered procedure.
If the DS is not covered...well, we'll go from there, I guess.

 

[BigBedRock]

Hi Betty and welcome! You'll find a wealth of solid information and support here.

I have Aetna HMO and had my DS 3 weeks ago with Dr. Bonanni in PA. Insurance has paid for everything (with the exception of a couple of $25 co-pays for some of the pre-op specialist testing) and I must say it's been easier than I expected! Everyone's specific plan is different so you'll need to find out the details of your plan, but mine required either 6 months documented diet or 3 months 'must-disciplanarey' program. The later turned out to be the surgeon's pre-op program which I needed to do anyway so I went with than option (3 visits w/nutritionist, 1 w/psych, 1 support group, tons of pre-op specialist testing, a pre-op class/exam, and detailed consult with the surgeon). One referral from my PCP covered everything.

Hope you're insurance experience goes smoothly. First step - get a copy of your specific plan then call Aetna to confirm everything. Good luck!

@JuliaDS Your experience gives me hope and discourages me at the same time. Haha. Could you tell me more about how Dr. Bonanni was chosen? Did the referral from the PCP specifically list Dr. Bonanni? Did it specifically list the DS? Did YOU choose Dr. Bonanni or did your PCP or did Aetna?

Everytime I have called Aetna's customer service phone number I ask if the DS is covered. Everytime (probably 8 times now but would have to look at my notes to know exact number) I am told that, yes, it is covered. I know that isn't the same as having the EOC in hand and seeing it in writing, but it gives me hope.

Thanks for your encouragement
Betty

 

[JuliaDS]

@JuliaDS Your experience gives me hope and discourages me at the same time. Haha. Could you tell me more about how Dr. Bonanni was chosen? Did the referral from the PCP specifically list Dr. Bonanni? Did it specifically list the DS? Did YOU choose Dr. Bonanni or did your PCP or did Aetna?

Everytime I have called Aetna's customer service phone number I ask if the DS is covered. Everytime (probably 8 times now but would have to look at my notes to know exact number) I am told that, yes, it is covered. I know that isn't the same as having the EOC in hand and seeing it in writing, but it gives me hope.

Thanks for your encouragement
Betty

I chose Dr. Bonanni. My PCP recommended the practice and I chose him from the 3 surgeons in the practice. The PCP recommendation was just that - not a specific referral, just a recommendation based on the positive experience of some of my PCP's other patients. I called the practice myself and set up the consult. I didn't mention the practice or the specific surgeon to Aetna and they didn't ask. When I called Aetna, I told them my group number and ID number and told them I needed to know exactly what was covered under my specific plan and what the requirements were and they told me. Then I went to HR at work and got a copy of the plan, read it, then I called Aetna back to confirm what I read. It is really important know the details of your specific plan. Aetna covers DS but your plan may not or may not for your specific circumstances. Hang in there and get a copy of your plan!

 

[BigBedRock]

I'm very thankful for the warm welcome everyone has extended to me and all of the offered advice and encouragement. I now have the EOC in hand... and from what I can tell the DS is not excluded and it is even included in the list of bariatric surgeries. But it looks to me that I must have a referral from my PCP to a specific specialist, so that is contradictory to what the PCP's office staff told me. I think I should post about this on the DS forum, but wanted to thank everyone for their support.
Betty