Insurance and being duped...

[Matt Balmer]

So, here's the short version. I go and visit a WLS clinic in Fayetteville, AR about having a DS procedure done. They do their spiel, etc, get me visits with a nutritionist, and all that jazz, and now I'm approved for a surgery on Jul 2.

Except that the surgeon is billing a SIPS/Loop/SADI procedure as a DS (you only find out it's a "Modified DS" after explicitly clicking his little link under the "procedures offered" menu). I have called his office and asked him the usual questions (two anastomoses and a 150cm common channel) and was told that he does one anastomosis and a 300cm common channel.

So I go on the hunt to find a surgeon that actually does do the surgery I want. After numerous recommendations, I hear about Dr. Ayoola in TX.

My only problem? He's not covered, my insurance has flat-out told me that unless I do the procedure at one of their six contracted hospitals, it's not covered and I'm out-of-pocket for the whole thing, and that while they are understandably concerned that the doctor is deliberately mis-coding the surgery to get it covered under the rules, that doesn't matter because Ayoola's hospital isn't on their exclusive (as in six hospitals, four in OK and two in AR) list. I check the remaining hospitals, and only one other even offers the Loop (again, termed as a DS), while none of the others even mention it.

So now I'm positively terrified about the whole thing, worried that I'll either have to settle for a substandard procedure or none at all, and that if I end up going through with this thing I'll be in for a world of hurt because I was duped.

Is there any way to get around the (incredibly stupid) insurance concerns? For the record, my insurance is HealthChoice Oklahoma. It's the standard plan made available to public school teachers statewide.

 

[southernlady]

Matt Balmer I moved your thread and am tagging the two people willing to help you do the work to get the surgery YOU want. DianaCox and Larra

They will help you appeal but you have to actually do the work. Listen to them, they have helped many succeed.

In the meantime, get your Evidence of Coverage from the HR dept. You will also need to document everything, time, date, person you talked to, etc.

Good luck. It may take time but it’s worth the effort to fight. Do not settle.

 

[Matt Balmer]

In the meantime, get your Evidence of Coverage from the HR dept. You will also need to document everything, time, date, person you talked to, etc.

I'm not sure what this is, and since I work for such a tiny school, I'm afraid that the folks in the superintendent's office (the closest thing we have to HR) won't know either. What is this?

 

[southernlady]

I'm not sure what this is, and since I work for such a tiny school, I'm afraid that the folks in the superintendent's office (the closest thing we have to HR) won't know either. What is this?

The Evidence of Coverage is a fairly long document (80 plus pages) outlining the details of your policy. I believe HR is required to provide that document yearly to its members.

 

[DianaCox]

You need to contact HR and get a copy of your EoC, AKA your insurance CONTRACT. NOT a summary of benefits - the actual policy. You need to find out if your plan is self-funded or fully funded - it matters what your appeal rights are.

The basic argument is going to be that you are entitled to chose among ALL standard of care procedures for treatment of your disease of morbid obesity. Not only is a proper 2-anastomosis DS a standard of care procedure, the SADI/SIPS/loopDS/single anastomosis procedure IS NOT STANDARD OF CARE - it is still experimental and the long-term results are looking BAD. https://www.soard.org/article/S1550-7289(17)30428-8/pdf#/article/S1550-7289(17)30428-8/fulltext (pathological in this context means not normal - it is in fact the malabsorption that is the purpose of the DS):

"Breath test for fat malabsorption showed pathological results for 77.78% of patients of DS and 60% of SADI-S after three months. At 12 months, these pathological results were found in 85.7% of DS patients, but no SADI-S patients had fat malabsorption."​

Fat malabsorption is what makes the DS work long-term.

If your in-house providers cannot perform a standard-of-care procedure, you are entitled to seek a provider who can perform it by someone who does, and your insurance should have to pay for it out-of-network at in-network cost to you. But we need to see your contract first to see how best to pursue this approach.

 

[Munchkin]

Sorry this has happened to you! Listen to DianaCox and it will all work out. Usually you have to fight to get the best and the DS is no exception to that rule. And BTW that doc who tried to dupe you is probably guilty of fraud. Probably defrauding the insurance company as well.

 

[Matt Balmer]

At the very least defrauding the insurance. Said doctor does define the surgery he's doing correctly in technical terms, but he labels it as a "Modified DS" and only actually classifies it as such when you click the link for that specific surgery on the menu (in other words, in the dropdown list of surgeries he does, he calls it a DS, but when you click on it, it's "modified", and when you read up on it more, you learn that's not what's really going on.

I have a call in to my superintendent's office to try and get hold of the EoC document. I'm hoping she knows what it is.

 

[Larra]

Matt, I'm sorry you are going through all this, but even sorrier for the people who weren't as careful as you were and are being fooled. I'll be even sorrier for them if their insurers figure out THEY were also fooled and come at these patients retroactively for payment for a procedure their policies didn't really cover. And we've seen that happen. We've also seen people who thought they had a DS find out they had a SIPS only a year or so later when their results were not what they anticipated and they requested their operative notes.
I have nothing to add to Diana's advice at this point, but it's better that you are dealing with this now than post-op, for sure.

 

[Matt Balmer]

So I'm just making posts to this as a documentation of everything I've done so far.

I got a call back from the superintendent's office. She had no idea what the EoC document was and gave me a number to call. That number didn't really help, as it seemed more related to handling and setting up claims as opposed to information.

I then called one of HealthChoice's main customer service number. After a short conversation, the representative informed me that I had to speak to someone in the "member services" department (isn't that what I'm calling??) and offered to transfer me. Upon transfer and a short discussion regarding the document in question and what was going on, she transferred me back to "claims" where I was essentially put back into the automated queue.

After talking to the folks in the claims department, the CPT code that I've seen referenced multiple times (43845) comes back as a non-covered code — and while they're going to mail the EoC document to me, that code for a DS is not covered. This, despite the coverage information on their website specifically stating that a DS is one of the covered procedures.

So now I really feel like I'm back to square one.

 

[galaxygrrl]

Ugh....sorry this is happening to you. DianaCox and Larra can help. Hang tough....you will get there. It's worth the battle.

 

[Larra]

All the more important that you see the full EOC. It will spell out, in detail, exactly what bariatric surgery coverage you have (or don't have). Incidentally, the code in question specifies not just "the DS", but also spells out details, such as having 2 anastomoses and a maximum length of common channel - which means that when surgeons use this code for their modified DS/SIPS/SADI/loop DS, they are not doing the operation they are being paid for.

I should have said this earlier - document everything, as you are wisely starting to do. With every phone call, make a note of date, time, name, job title, phone number, and brief summary of the conversation. And don't be shy about requesting to speak with supervisors/managers. Go up the food chain as far as you need to to get that EOC.

 

[k9ophile]

Your insurance company will employ many schemes to make you want to give up. They don't want anyone to file claims so they can impress shareholders with their profits. It's their "job". Your job is to never give up. Never. Ever. You'll get great advice here. To borrow an old hymn I remember from my church going days: trust and obey. Diana and Larra are The Best when it comes to insurance questions.

 

[DianaCox]

Matt - Larra and I have been helping people with appeals for the DS pro bono for over 10 years. Our record is over 90%. We’ve seen a wide variety of tactics and while most of the situations have one or more unique aspects, the majority of issues in the majority of cases are things we have dealt with before. Your situation is annoying familiar to us (annoying because it is frustrating seeing these insurance mofos continually putting forth false, fraudulent denials), so trust that depending on what your contract specifically states, and whether your plan is self funded or fully funded (did you get that information?) and what state law controls (where is your company headquartered?), we'llprobably be pulling our information from our bag of tricks.

In the meantime, does your insurance require any pointless stupid diet or weight loss or nutrition classes? If so, find out what they are and start complying. Saves time while we’re fighting for approval.

 

[Matt Balmer]

Diana - I spoke with a person from the claims department who said they would mail me an EoC document. 7-10 days.

My insurance company appears to be HQ'ed out of Lubbock, TX. That's the mailing addresses for "submissions", but they also link back to the Oklahoma State Insurance Board, so I'm not fully certain.

As for "classes," I've already done them. The insurance only required two visits with the nutritionist (as opposed to 6 for some others, from what I've been told) and the surgery is green-lighted. Which is the situation I'm in: I have had labs done, and I've completed both nutritionist visits, and the surgery has been scheduled for July 2. From their perspective, everything is on track and good. From mine, I've got some questions that remain unanswered.

I did finally get a call back directly from the doctor who will be performing my surgery and he did his best to calm me down. I quoted the study you referenced above in the ASMBS journal, to which his retort was that in his experience, "the reason you don't see much malabsorption after 12 months is because people tend to plateau after 12 months — but the important thing we've seen with our surgeries is that while they tend to stop losing weight, they don't typically gain it back."

His claim for why they stopped doing the classic DS is, in his opinion, complications that arise from the surgery, specifically gallbladder issues, blockages in the intestine, and severe malnutrition issues that are extremely difficult to control.

I asked him a number of other questions regarding gallbladder removal, appendectomy, NSAID use, complications and other things, all of which he seemed to answer genuinely. He also offered to, at the time of my pre-op screening (June 28) provide me with further studies and more data if I so desired, and to discuss further things about what I was wanting. He also said that I could feel free to call him back if I developed further questions, and he was glad to hear that I was asking targeted, detailed questions.

 

[DianaCox]

“in his experience, "the reason you don't see much malabsorption after 12 months is because people tend to plateau after 12 months — but the important thing we've seen with our surgeries is that while they tend to stop losing weight, they don't typically gain it back."“
​

That doesn’t make any freaking sense! The malabsorption - which is what prevents regain and which is related to the metabolic improvements - is NECESSARY to maintain weight loss long-term! Look at RNYers who do well for the first 4-5 years, and then look at them at 10 years.

He’s confusing malabsorption with weight loss - which really concerns me. We REAL DSers plateau too, but we continue to malabsorb, which maintains our weight loss while eating a high protein, high fat diet that is often more food than we used to eat preop, and maintains our freedom from comorbidities. Without macronutrient malabsorption, which is apparently what happens over time to the minimal malabsorption provided by the SADI/SIPS/LoopDS, and which is so minimal that the body is able to adapt and overcome it, you have a sleeve with a pointless intestinal rearrangement, but also permanent micronutrient malabsorption!

His claim for why they stopped doing the classic DS is, in his opinion, complications that arise from the surgery, specifically gallbladder issues, blockages in the intestine, and severe malnutrition issues that are extremely difficult to control.​

Who is this guy? Name please. We know very few real DS surgeons who used to the classic DS and started offering SIPS instead. In competent hands, gall bladder issues aren’t even an issue, other than for those people whose surgeons don’t remove them at the time of surgery, so the patient ends up back in surgery a few months later. Intestinal blockage is a risk from ALL abdominal surgery. And severe malnutrition is rare, when the surgeon is competent and the patient is compliant.

WARNING WILL ROBINSON!

It’s not clear to me whether your appeal is in TX or OK. In any case, you need to know whether it’s self funded or fully funded plan.

I strongly urge you to seek a second opinion with Dr. Ayoola in TX (Denton?). He’s an excellent REAL DS surgeon.