No DS doctor in state and in network

[Rutb]

I am need of some advice. I have already verified that any weight loss surgery is covered by my plan as long as I use an in network in state doctor. I even called member services and verified the procedure code for DS is covered. Everything is great I thought until I called Dr. Elariny's office and found out he just recently dropped my insurance company Anthem health.

Bummer. I then called back member services to find out what my options would be. turns out that I can get a referral for wls and the submit for pre authorization to see a doctor out of network but in state since none one else in Virginia does this type of surgery. The member services agent then let me know that the surgeon's office will do all the paperwork for approval.

My questions:
1. Should I trust the surgeon's office to do everything necessary to get approval?

2. For those that have experience putting through claims, have you seen this situation get approved the first submittal? My husband actually works for the parent company and the eob and everything I read seems to point towards them approving rny and other procedures. However, I want to get the DS because it provides the best outcome for type 2 diabetes and long term maintenance of weight loss.

3. Even if the doctor is out of network, what about if the OR and hospital is in network, would they just pay the contracted rate for those charges? Insurance billing gives me a head ache and I haven't had to deal with figuring it out before. The member services agent assured me they would, but I am skeptical.

Thanks for your time. I am using my phone for this post so hopefully there are not too many errors.

 

[newanatomy]

I have BCBS/Anthem and was able to have my surgery covered out of state. I just needed to have a hospital that was a COE and an in-network surgeon. I am no insurance expert but @DianaCox is. I am sure she will try to help you.

Good luck to you and welcome.

 

[Rutb]

Because my husband is an employee of the company, we have different set of rules than if we had the same insurance through a group policy under a non anthem employer. I was told that as an employee we could only go in state and in network. Given the small number of surgeons that are qualified and experienced, I am not sure how likely I am to win the argument to break either clause.

 

[southernlady]

Because my husband is an employee of the company, we have different set of rules than if we had the same insurance through a group policy under a non anthem employer. I was told that as an employee we could only go in state and in network. Given the small number of surgeons that are qualified and experienced, I am not sure how likely I am to win the argument to break either clause.

Depends on who funds the policy. Get a hard copy of your evidence of coverage and then contact @DianaCox for help.

 

[Rutb]

Depends on who funds the policy. Get a hard copy of your evidence of coverage and then contact @DianaCox for help.

Thanks, I will. After reading this board some more, I am not hesitant about the surgeon I am choosing because he stated to me that he now prefers to do the DS in patients with a BMI > 55 in 2 parts. I don't really want a 2 stage surgery and from what I've read that isn't as optimal for the patient. I would rather have plastics as the second surgery. I would like the option to pick my surgeon based on facts of outcome rather than what insurance will cover.

 

[DianaCox]

It is difficult to figure this out in a vacuum - I will need to see your insurance contract (usually called something like "Evidence of Coverage" document - it should be around 80-100 pages long). You need to find out whether your insurance plan is fully funded or self-funded. Since Anthem is the employer, I'm guessing self-funded is more likely.

Next question - who is the surgeon you were planning to go with who wants to do your DS in two parts? Elariny?? That would be disappointing indeed. But I also think that recently, a couple of other VA surgeons started offering the DS. They of course would not be as experienced as Elariny, but if Elariny insists on doing the DS in two parts, I would not be using him anyway.

You need to check out the hospital separately - I suspect most hospitals would be in-network with Anthem. I had that situation when I had my DS - Rabkin was out of network, but CPMC was in. You also need to check in advance about the anesthesiologist - I've seen multiple cases where the anesthesiologist was not in-network and the insurance company balked at paying for it - as IF the patient had a choice about who the surgeon used!

 

[Rutb]

Hi Diana,

I sent you a PM with a little more detail since I don't want my whole history spread across the internet. I have my EOC, but I couldn't figure out how to attach it to the PM.

I was planning on using Elariny, mainly because a phone routing issue connected me directly to him and he answered the phone and then called me back when he had a free moment. I was impressed with that. He said he would do the surgery at one time if there was a question as to whether the insurance would pay for a revision. I am not interested in doing a 2 parts and he isn't insistent it is done in two parts, so it may work out. I know he has a very good track record and I am only 2.5-4 hours (depending on traffic) from NoVA. I will make sure my consent form states I only want the DS and just a sleeve is not what I want.

Also, having the surgery in TN or closer to Richmond would be easier to get family to help look after me during recovery. I checked and Dr. Boyce appears to be doing the DS in TN (he seems to have good stats despite not being on the vetted list). I would be interested in finding out what other surgeons are doing the DS and where they are located. I am in Richmond, so Hampton Roads (i.e. Norfolk, Newport News, Hampton, VA Beach, etc) or Richmond would be really good for my recovery since my MIL is familiar with these areas too. She doesn't do very well in big cities like DC. I guess that if my EOC doesn't limit me from going out of state, then I may have a wider net to cast for surgeons.

 

[DianaCox]

You are going to have to do investigation, and - yes really - Anthem will LIE to you. You need to get the name of EVERY person you speak to, write down what is said, ask them to put their comments in writing and send it to you, etc. You should have options to go out of network to get a proper DS surgeon, and if a closer surgeon is in a neighboring state, you should have the right to see them too. (BTW, Boyce isn't always the easiest person to deal with either, as I'm sure you have seen.) Ask the questions, and get the answers in writing.

 

[Jbandmmomma]

There is another choice in NoVA now. Dr's Glembot and Wiedower, at Winchester Medical Center. There is a link in my siggy to their practice's webpage. Check them out. They were trained by Dr. Boyce. Their entire staff and every single person in the hospital treated me with utmost care and respect. I highly recommend you checking them out.

 

[Jbandmmomma]

Thanks, I will. After reading this board some more, I am not hesitant about the surgeon I am choosing because he stated to me that he now prefers to do the DS in patients with a BMI > 55 in 2 parts. I don't really want a 2 stage surgery and from what I've read that isn't as optimal for the patient. I would rather have plastics as the second surgery. I would like the option to pick my surgeon based on facts of outcome rather than what insurance will cover.

Also note that Elariny bills for out of network and you will have to pay ~$6000 upfront to even get surgery scheduled. This is the reason I kept looking, in addition to feeling like I was just a widget about to get counted when I had my consult with he and his staff.

 

[Rutb]

I am going to have to do more doctor research. just for those reading and considering Dr Elariny, he was not pushing for a 2 part only. He says he does the procedure in 1 procedure if you are under a 55 BMI or if you insist as a person with BMI > 55. I just want to be fair about the conversation. I realize now I may have alluded that the conversation went otherwise.

 

[Rutb]

There is another choice in NoVA now. Dr's Glembot and Wiedower, at Winchester Medical Center. There is a link in my siggy to their practice's webpage. Check them out. They were trained by Dr. Boyce. Their entire staff and every single person in the hospital treated me with utmost care and respect. I highly recommend you checking them out.

Did this practice start performing the DS in 2014? I ask because on their 2013 data sheet for referring providers, they don't have any metrics for DS surgery. How many DS surgeries have they performed and of those how many were on folks with BMI > 55? I will call tomorrow and see if I can find out, but if anyone else knows please let me know.

 

[Jbandmmomma]

I was their second DS (lap) at their facility. They were trained by Dr Boyce and he traveled here to proctor the surgeries done on my date. My surgery only took 2 hours, even though projected to take 3 hours. They are committed to providing the DS to patients in this area. My surgery was on April 18, 2014. I really have been pleased with the practice and people so far. This was the third surgeon I consulted with and my final choice. I have no regrets. My BMI was >55 also. Check out their website. You should be able to do the info session online.

 

[Walter Albert]

Reading this thread im thankful I was able to get a ds with a bmi of 35 just took 5 years and 5+,appeals & consults with every ds surgion in nyc

 

[DianaCox]

Welcome Walter!