Insurance requires high BMI for DS?

Discussion in 'Duodenal Switch' started by Remingtonh, Jul 13, 2018.

  1.  
    Remingtonh

    Remingtonh Well-Known Member

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    Hi all, I decided to move my thread over here since I've hijacked the other thread enough already.

    I just got off the phone with Dr. Ayoola's office, and we talked at length about insurance and the DS (with the staff not the doctor).

    They essentially told me that, though it's not the "official" policy of their practice, they tend to not do DS surgery on patients with less than 50 BMI, because insurance companies make it difficult.

    I advised them that I spoke with my insurance company in detail and they told me that my policy covers the DS, and there is no differentiation between 40 BMI or anything higher.

    I asked her about the pre-authorization process, and what she told me matched what the doctor told me, in that even if the surgeon gets pre-authorization from the insurance company, schedules the surgery and completes it, the insurance company can still deny coverage when it comes time to pay the claim.

    I pointed out that if that's true, then it could happen with any surgery, not just the DS. So my thinking is that the doctor believes there is a greater chance of that scenario occurring with the DS vs. RNY or other lesser procedures, and requires prepayment for the procedure, with the expectation that the insurance company may ultimately deny the claim.

    It seems Dr. Ayoola's office might have the same concerns as the doctor. I haven't moved that far with them yet, but that's definitely what they were suggesting to me.

    Unfortunately this might mean the DS could be out of my reach at this point. I just don't know if I'm willing to risk $8K. I'll have to seriously re-think this.

    Has this happened to other people seeking DS surgery?
     
    Last edited: Aug 6, 2018
  2.  
    DianaCox

    DianaCox Bad Cop

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    If you have preauthorization from your insurance, you are protected, assuming that the surgeon DOES THE PROCEDURE YOU WERE PREAUTHORIZED FOR. Part of the preauthorization package is your BMI, so they can't retroactively say you shouldn't have been given the procedure.

    I think the insurance people in those surgeons' offices are just LAZY. They don't want to deal with possibly iffy cases that might require a little more work for them to help the patient. Despicable. You shouldn't have to convince them to do their damned job.
     
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  3.  
    JackieOnLine

    JackieOnLine Moderator Staff Member

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    exactly - I don't blame you a bit.
     
  4.  
    DianaCox

    DianaCox Bad Cop

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    Exactly. And it makes me VERY suspicious about what surgery they're doing if they submit preauthorizations and then don't get paid.

    Now let m be clear about one thing - there is one circumstance under which this is "reasonable." I had to pay Rabkin $4000 upfront, because he was not in-network on my PPO (although the hospital was). Nobody had any idea how much my insurance would pay of his fee, but I would be balance-billed for the difference. That was upfront and known. $4000 was 1/3 of his fee at the time (15 years ago). After insurance paid, amazingly, they paid a bit over 2/3 of his fee, so I got a refund of the excess.

    But if your surgeon is in-network, there is no reason that you should have to pay anything except perhaps the deductible/copay in advance.
     
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  5.  
    Remingtonh

    Remingtonh Well-Known Member

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    Today I confirmed with Dr. Ayoola's office that, if insurance provides the pre-authorization/approval, they'll do the DS.

    Still haven't spoken with the doctor yet, I have an appointment on Friday.
     
    Last edited: Aug 6, 2018
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  6.  
    Remingtonh

    Remingtonh Well-Known Member

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    Finally talked to the doctor. Had a long in-depth discussion with him, he explained everything, and it does make sense - and he acknowledged that insurance billing problems he's had ~10 years ago may have been resolved since.

    He has agreed to do the DS! Submitting to insurance today I believe.
     
    Last edited: Aug 6, 2018
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  7.  
    DianaCox

    DianaCox Bad Cop

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    FYI: If you get insurance approval for the DS with Ganta, you can probably move it to Ayoola if you want.
     
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  8.  
    Remingtonh

    Remingtonh Well-Known Member

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    I see no reason to do that at this point. The doctor did warn me however, that about 10-15% of DS patients need revision because of malabsorption problems. Nobody has mentioned that here before. ..
     
    Last edited: Aug 6, 2018
  9.  
    Larra

    Larra Well-Known Member

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    Good grief, where did he get THAT number??? Way off base. If you read the Hess study, which included almost 1000 DS patients who were followed for 10 years, only a couple needed revision, and even for them it was almost always due to noncompliance. I'm not saying bad things can't happen, but they are far less common than he's stating.

    And, on the subject of revisions, look around you. You will see a huge number of unfortunate people with lap band revising (or at least having their bands removed), a fair number of people with sleeves revising to something that works better after a few years when the sleeve stretches out, and even some folks with gastric bypass revising to the DS, which is a huge, high risk operation. And it is my belief (can't prove it, so I won't present this as fact) that we would see even more such revisions if people could get insurance coverage. It's far more difficult to get coverage for a revision than for a primary bariatric surgery, often impossible. So, there is no perfect, risk free option, but would you rather take on the small risk of revision with DS due to nutrition issues or the substantial risk of revision and/or failure with a less effective operation?
     
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  10.  
    RainCity

    RainCity Well-Known Member

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    Why are you going through with DS surgery with Dr. Ganta instead of with the awesome surgeon, Dr. Ayoola?
     
  11.  
    Remingtonh

    Remingtonh Well-Known Member

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    I have no reason to believe Ganta isn't perfectly skilled and qualified. Plus Denton TX isn't exactly close or convenient.
     
  12.  
    southernlady

    southernlady Administrator Staff Member

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    We’ve had people travel half way around the world to get the DS. Close isn’t worth it if not done correctly.

    He may be skilled but our concern is lack of knowledge within the vet community. No one I know on this forum or in four of five DS groups on FB has heard of him as a DS surgeon. And the one group that did, the post was from 2011.

    I know you want to be close, I get that. But if you were having heart surgery, would you want close or good? Same skill level in many ways.

    If you stay with Ganta, make him draw you a picture of what he’s gonna do, listing limb lengths for you. Make sure the CPT code is correctly submitted. Make sure your surgical consent form specifies each limb length and the only two alternatives to a lab procedure of the DS is possibly going to open instead of lap or close up without proceeding at all.

    There are many surgeons who get in and decide to stop with just a sleeve because “the DS was too much, too hard, etc”, leaving the patient screwed.
     
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  13.  
    Remingtonh

    Remingtonh Well-Known Member

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    Thanks for these suggestions. I really do think Ganta is a skilled surgeon, and we talked about the procedure - of course I wanted to make sure he was doing a proper DS not a loop/sadi or whatever. He said he usually does 100cm common channel and he suggested his sleeve is a little larger than he would make it for a sleeve gastrectomy. Maybe some of these things are negotiable.

    You mentioned he should list limb lengths. I understand why the common channel is important, but are there particularly ideal limb lengths? My date has been moved, tentatively, to August 13th, so I have a bit of time to consider all this.
     
    Last edited: Jul 20, 2018
  14.  
    Larra

    Larra Well-Known Member

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    It sounds like he does a cookie cutter DS - which isn't the end of the world, though it would be best if he used the Hess method to determine limb lengths. But for a cookie cutter DS, a 100 cm cc is very reasonable. Also, making the sleeve larger than he would for a sleeve stand alone is fine as well. Many surgeons deliberately make their stand alone sleeves extremely narrow in hopes of avoiding a stretched out sleeve later on. This doesn't necessarily work, but for sure if they make a more generous sleeve it won't work for long by itself. It's the malabsorption of the DS that helps us so much to maintain our weight loss.
     
  15.  
    RainCity

    RainCity Well-Known Member

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    I live in Washington but am in Southern California for surgery with Dr. Keshishian next week. It’s critical to me that an expert surgeon operates on my GI tract, regardless of travel challenges.
     

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