Attention Dr. Sudan Medicare patients

southernlady

Administrator
Staff member
Apparently Dr. Sudan's office is stating that Medicare requires a 6 month diet...HOGWASH. All it states is previous FAILED ATTEMPTS!

One of our members found this out:
I had a VERY long and detailed discussion with the Durham Regional manager of Revenue Enhancement, which is part of the Business Office. She walked me thru and then emailed me copies of each and every National and Local Decision Memo regarding Bariatric Surgery that the Medicare/caid contractor we in NC use has published. The 6 months is not spelled out anywhere and she said if I want to try to put it through with less, we can give it a go but if Medicare doesn't honor the claim I am responsible for the full charges.
 

Elizabeth N.

Herder of cats
Hmmm. Pardon my snarkiness, but I wonder if this is an effort to not have to take on as many (poorly reimbursed) Medicare patients without attracting notice.
 

Elizabeth N.

Herder of cats
Okay, I'll retract my grumpiness and put it somewhere else :). (I'm cranky because that black beast in my avi just pulled a Houdini and missed a much needed vet appointment, for which I rearranged my whole fucking WEEK.)
 

southernlady

Administrator
Staff member
See, the thing is...Medicare does NOT do pre-approvals... ALL of us who use Medicare have to hope and pray it is paid for AFTER the surgery. We have nothing ahead of time that tells us they will.

However, IF you have 1) documented FAILED attempts by doctors (NOT necessarily the surgeon) 2) are over a 40 BMI or a 35 BMI with a recognized comorbid: Diabetes, sleep apnea then they usually pay as long as all the boxes are checked off prior to surgery. AND if the surgeon/hospital code it correctly.

Most surgeons won't even TAKE Medicare cause the reimbursement is so low. AND it takes forever to get paid.

I do know that NC is one of the hardest states to get WLS in regardless of who pays except for SELF PAY. It's like the entire state wants everyone obese.

IF Boyce had not started doing such huge sleeves, I say go there since apparently TN isn't included in this mess. However, the only Medicare patients Boyce is seeing are those who are already patients. Williams is the one in that office handling Medicare patients now and HE won't do a DS on a lightweight REGARDLESS of reason.
 

Elizabeth N.

Herder of cats
Black kitty's appointment was for 3:30. I called the vet to cancel at 3:00. Shitlist Kitty was on his perch eating at 3:45. He is rescheduled for Saturday morning and will be confined in the dog's crate on Friday. The little fart REALLY needs to see the vet, as he is quite unwell. If he goes south and costs me next month's mortgage in kitty ER expenses before Saturday I'll be seriously pissed.
 

Brandy Rediker

Well-Known Member
This is from AARP United Health Care Medicare Complete requirements for my mom's 6 mos diet:


Additional information for medical necessity review, where applicable:
Bariatric surgery is medically necessary when ALL of the following criteria have been met:

Body mass index (B
MI) = or > 40 kg/m2 or BMI 35.0
-
39.9
kg/m2
with one or more of the
medical comorbidities described above.

Documentation of a motivated attempt of weight loss through a structured diet program,
prior to bariatric surgery, which includes physician or other h
ealth care provider notes
and/or diet or weight loss logs from a structured weight loss program for a minimum of 6
months.

(NHLBI, 1998)

Psycol
logical evaluation to rule out major mental health disor
ders which would
contraindicate
surgery and determine pat
ient compliance with post
-
opera
tive follow
-
up
care and dietary
guidelines
. (

NHLBI, 1998


There is nothing in this statement about FAILED ATTEMPTS. So we will see where this goes with her dr. documentations about her fluid retention.
 

southernlady

Administrator
Staff member
Okay, it does NOT say it has to be the bariatric surgeon or his office...and her cardiologist and PCP can provide that information.

Does it say it follows the Medicare guidelines? If so, they are the ones who say FAILED ATTEMPTS.
 

Brandy Rediker

Well-Known Member
I don't know I'll have to go back over it and reread it all over again. I know they are contracted in with Medicare. Does that matter any?
 

southernlady

Administrator
Staff member
Yes, because they are SUPPOSE to follow the Medicare guidelines listed here:
http://bariatricfacts.org/threads/cms-center-for-medicare-medicaid-service-wls.316/
http://bariatricfacts.org/threads/cms-center-for-medicare-medicaid-service-wls-standards.317/
The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.
Bold & red is mine.
 
Medicaid was a beast to maneuver. It took me being a constant advocate for myself, making calls/emails/researching every single day for two years. I submitted months of dietary data...the last few months the data was enormous (BS's, Protein value, Carbs, calories, etc...) & the spreadsheet was nearly unreadable. They still tried denying me. Basically, I had to jump through invisible hoops! I have approval for my March 24 surgery! But, the last re-certification and this upcoming one, they are trying to cut me. So, I battle on!
 

southernlady

Administrator
Staff member
Medicaid was a beast to maneuver. It took me being a constant advocate for myself, making calls/emails/researching every single day for two years. I submitted months of dietary data...the last few months the data was enormous (BS's, Protein value, Carbs, calories, etc...) & the spreadsheet was nearly unreadable. They still tried denying me. Basically, I had to jump through invisible hoops! I have approval for my March 24 surgery! But, the last re-certification and this upcoming one, they are trying to cut me. So, I battle on!
Tammy, unfortunately Medicare and Medicaid are NOT the same beast. The states control how Medicaid is handled even tho it does receive federal funding. Medicare is a federal entity.
 
I am aware that they are not even remotely the same. Actually, North Carolina declined to receive federal funding for Medicaid...part of why it's so messed up I guess. I was just hoping to be of some help to anyone going through the process with Medicaid(or Medicare), and know that there is someone out here to understand :)
 

southernlady

Administrator
Staff member
I am aware that they are not even remotely the same. Actually, North Carolina declined to receive federal funding for Medicaid...part of why it's so messed up I guess. I was just hoping to be of some help to anyone going through the process with Medicaid(or Medicare), and know that there is someone out here to understand :)
Actually NC (and others) declined ADDITIONAL Federal funding. In 2012 (last data available)
http://kff.org/medicaid/state-indicator/federalstate-share-of-spending/#table
Location Federal State Total
North Carolina $8,036,081,928 $4,246,370,409 $12,282,452,337
So the federal portion is 65% in 2012.
It's just messed up cause it's messed up.
 
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