Insurance and being duped...

[Larra]

Like Diana, I've been active in the DS community for over 12 years now (for her even longer) and I've never heard of any surgeon in Arkansas doing the DS at all. I doubt this surgeon was doing the DS, certainly not frequently enough to make our radar.
Gall bladder - problems with gall stones post-op are related to rapid weight loss, regardless of how that weight loss is achieved. If he is concerned about this - and it is a valid concern - he can routinely remove the gall bladder at the time of your surgery, as my surgeon did. It serves no function after the DS anyway, would add maybe 10-15 minutes to your surgery since he's right there anyway, and would prevent any potential gall bladder issues.

I can't add anything to Diana's excellent explanation of the difference between malabsorption and weight loss, and why we do so much better maintaining our weight loss with the DS than people do with other operations.

Nutrition - if the patient is properly educated (many are not, sadly, because of poor advice given by surgeons and/or their staff) and compliant, nutritional problems are very infrequent with the DS. There are excellent long term studies of large groups of patients that document this. Yes, some patients do get into trouble, but usually because they were told to "just take ADEK's" or given the same nutritional recommendations as someone with gastric bypass, or some other bad advice. And we've certainly seen some people who decided they were special and didn't need the same vitamins and minerals as the rest of us. But you seem like a very smart, diligent person who will do what it takes to stay healthy. Why should you not get the operation you have concluded is best for you just because someone else screwed up?

 

[Matt Balmer]

So, i got a call back from Dr. Ayoola’s office. The patient advocate basicallysaid there was nothing that they could do, and that the fight was solely between me and my insurance. On top of this, her statement about coverage was that they absolutely can deny me coverage even if the desired surgery isn’t offered in-network.

DianaCox : The surgeon in question is Dr. Josh Mourot, who is a part of Roller Weight Loss in Fayetteville, AR.

As of right now, I'm waiting to receive my EoC document.

I will not sugar-coat it: I am feeling discouraged enough that I’m tempted to just call the whole thing off and forget it. I’ve had enough people passionately tell me that a true DS is my best option and that I should not settle for anything less, and I have very little tolerance for a protracted fight with my insurance which will wreck my already poor credit. I am bordering on tears because I want what’s best, and I’m being told that what’s on offer not only isn’t best, it’s actively worse.

I am positively terrified right now.

 

[Spiky Bugger]

Hmm...I wrote this hours ago but forgot to hit send. I fits in better on the first page, but here it is. (I was on "conscious sedation" yesterday and I'm sticking with this story.)


Matt,

Think about this for a minute:

If he REALLY thinks his "Modified DS" is so good, why did you have to research to find out that he's not offering the real DS? We call it "Bait & Don't Switch," and it's a common...uhm..scam.

More on point...
•many DS surgeons routinely remove the gall bladder. Problems can be caused by rapid weight loss...NutriSystem got sued for it years ago...NOT by the DS itself.
•malnutrition CAN OCCUR, if doctors and patients don't respect that we have surgically induced MALABSORPTION, which is how we lose weight. We don't get malnutrition if we do lab work and treat supplement shortages. (Thanks for the reminder, I've got a blood test today?)
•I think intestinal blockages can occur with many surgeries, but they aren't "common" with the DS.

You are anxious and that's when some doctors take advantage. Exercise caution. You are THIS CLOSE to making a really good decision or one with limited proven results. (And most insurances pay for one bariatric surgery...IF you haven't already had one. Then they pay for nothing.) So take a deep breath. Getting this done NOW is not as crucial as getting this done right.

Really.

 

[DianaCox]

1) Never heard of Mourat. I would stay away from Roller's practice. They do not and as far as I know never did the standard DS, and from what we have seen of previous people dealing with them, they are shady about full disclosure of what procedure they are really doing - wonder how they code the experimental SADI/SIPS/LoopDS when there is no CPT code for it?

2) "I have very little tolerance for a protracted fight with my insurance which will wreck my already poor credit." What does this mean? You fight the insurance fight BEFORE surgery. It will not affect your credit.

3) "The patient advocate basicallysaid there was nothing that they could do, and that the fight was solely between me and my insurance. On top of this, her statement about coverage was that they absolutely can deny me coverage even if the desired surgery isn’t offered in-network." We can help you fight your insurance company, and depending on what your EoC says and which state law controls the contract, you can in many cases still get around the exclusion.

 

[Matt Balmer]

DianaCox : I've learned that my only other "in-network" choice is Bailey Bariatrics of Owasso, who does the same thing as Roller's practice — perform a LoopDS while calling it a DS. They spell it out pretty clearly on their website (in fact, their procedure video even calls it a LoopDS).

As for the insurance fight thing, I was under the impression that I was going to end up fighting the insurance post-op. I'm still not hugely encouraged, but considering the alternative...

I did a little more digging, and found this information in the plan overview handbook:

Plan Administrator:
Office of Management and Enterprise Services (OMES)
Employees Group Insurance Division (EGID)
3545 NW 58th St, Ste 600
Oklahoma City, OK 73112

Claims Administrator:
HealthSCOPE Benefits
POB 99011
Lubbock, TX 79490

Would either of these things help determine which state laws hold jurisdiction?

As for self-funded/fully-funded, I found this little blurb at the bottom of the Healthchoice website (https://gateway.sib.ok.gov/providersearch/):

"We are a State of Oklahoma self-funded insurance plan covering state and local government, education and former employees and surviving dependents."

I should also add this, from the handbook, under the heading "Plan Exclusions and Limitations", after which it says "There is no coverage for expenses incurred for or in connection with any of the items listed below. This list is not all-inclusive" :

30. All treatments for obesity, including but not limited to morbid obesity, gastrointestinal tract modifications and all complications and procedures, even when obesity or morbid obesity is diagnosed, expenses for weight loss treatment, advise or training, except when performed at an MBSA-QIP certified-comprehensive center of excellence. Refer to the Preventive Services and Covered Services, Supplies and Equipment sections for certain coverage allowed for obesity screening, prevention and treatment. Plan limitations and exclusions apply as defined.
​

Under the "Covered Services" section, it lists this:

Bariatric Surgery

• Must be age 18 or older.
• Must meet specific criteria which includes, but is not limited to, severity of obesity, reliable participation in preoperative weight-loss program that is multidisciplinary, and expectation of adherence to postoperative care.
• Must be covered by HealthChoice 12 consecutive months before the surgery (after Jan. 1, 2017, all testing, lab work and consultations can be completed prior to the 12 months).
• Revisions or complications from any covered procedure that were originally obtained from a facility that was not a HealthChoice bariatric network provider or when the individual was not covered by HealthChoice are not covered.
• Procedures must be obtained from a Metabolic Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Comprehensive Center of Excellence contracted with HealthChoice.
• Services subject to plan deductibles, copays, coinsurance and the out-of-pocket maximum.
• Certification required for inpatient and outpatient services, refer to the Certification section.

(emphasis in both cases mine)

 

[DianaCox]

Yes, your plan is self-funded. That limits your appeal rights in some ways - the state doesn't control the plan. Instead, the plan only has to comply with the looser federal ERISA requirements, and ultimately, you MIGHT have to sue, as your appeal rights are limited in some cases. On the other hand, since the employer actually pays for the medical costs, they can overrule the plan themselves, if they want to.

HOWEVER: Dr. Ayoola's hospital is an MBSAQIP CoE (which is an utterly bullshit designation, designed to limit access of patients to surgeons who are in small practices, but in this case, the one you want to see operates at one - bonus!). But probably not contracted with HealthChoice.

Even if Ayoola is not on the list, nor is the hospital, the hospital meets the MBSAQIP requirements, so that's not going to be a hurdle - just seeing an out-of-network surgeon who provides a procedure that is not available to you in-network. We need to see what the plan document says (I know, you don't have it yet) about what your rights are when there are no in-network providers who do the standard of care procedure you want.

Trust me, I have overcome this restriction before - my daughter was in an Aetna HMO in a self-funded plan; she has stage 4 endometriosis, and the world's expert is at Stanford - but he was not in-network for her. They paid for her consult and surgery with him, and I made them sorry they fucked with me. And while it made me very very angry, I also rather enjoyed making them pay.

 

[Matt Balmer]

So I have an update of sorts. While I still have yet to receive the CoE document from my insurance, I did have another event happen.

Over the course of the past two weeks, I had serious bowel problems, to the point where bowel movements were both extremely painful in the moment as well as up to 8 hours following. I got checked out, and it turns out that I had an anal fissure, along with an overactive sphincter; the anal fissure was causing the immediate pain during a bowel movement, but the overactive muscle was clenching so hard in the hours following a bowel movement that the resulting pain was actually worse than what was going on during a trip to the bathroom.

I had surgery for this on Tuesday. The doctor performed a suture on the fissure, along with a hemorrhoid removal, and a lateral internal sphincterotomy that went about 1/3 of the way up the muscle.

Needless to say, this procedure not only made me hit my insurance deductible, but I've burned my way through about $1,000 of my out-of-pocket maximum for the year as a result.

I've heard that having the sphincterotomy done can be troublesome if you have a DS because of incontinence issues. Is this true?

 

[DianaCox]

I had a sphincterotomy on 1995, 8 years before my DS. No problem. But I’m UBER careful about not allowing a repeat performance, because I think the second one is more problematic.

 

[Whit]

Don't let the WLS Surgeon or fear of possible issues scare you into the path of least resistance. You will probably need to heal before another surgery so this gives you time to really consider all of your options.

 

[Matt Balmer]

I received what I thought was my EoC document from the insurance -- in reality, what they sent me was more like a proof-of-coverage statement listing what my monthly premium was. So I called them back, prepared to chew some ears off about how I had received the wrong document.

I spoke with Madison D., who not only listened to my story but appeared to be much more concerned about the issue of the surgeon coding one procedure and performing another than the other people I'd spoken to. After some discussion, she got approval from her supervisor to discuss specific insurance codes that were covered, and as it turns out, the code for a DS actually is covered after all. The other representative was looking at a slimmed-down list of insurance codes that the insurance company covers at a 100% rate for their members (as opposed to the 80/20 split after deductible for everything else), which is not a complete list of codes that the insurance covers.

So then came the inevitable question of, "well, what happens when none of the six hospitals you contract with offer the surgery you say you cover?" For that one, she didn't know, but she offered to do some legwork on her end to reach out to the six contracted hospitals to determine exactly what they were doing and whether one of them actually does offer a true DS, but doesn't advertise it. For right now, the insurance policy says that any bariatric surgery must be done with a contracted hospital, but she made it sound like they hadn't run into this particular problem before, so she wasn't sure whether or not they would approve me to go out of their network to get the job done — she'd have to confirm what was being done at the other hospitals first. She also seemed extremely concerned that one of the six hospitals was performing an unlisted procedure and coding it as something that was covered — her statement was that while it might appear to be covered in the immediate aftermath, if someone were to go looking at the surgery report afterwards they could determine that the actual procedure done didn't match the insurance's definition of the procedure and that could touch off a whole laundry list of problems.

In the meantime, I called the clinic I was scheduled to have my surgery with back, and informed them that I was canceling my pre-op appointment with them, as well as the surgery date. When pressed for a reason, I mentioned two things. The first being the emergency surgery I just went through to address an anal fissure and an overactive sphincter on my end, and the second, far more important reason: the deception that it appeared the clinic was going through to shove a SADI procedure through as a DS, and the resulting insurance problems that would result.

The woman on the other end of the line seemed taken off-guard when I told her the second portion. She claimed she had an authorization from the insurance company, and that "sometimes, the insurance company can't decide which code they want to take" so they "use both". In my mind, a thoroughly unsatisfactory answer. She offered to have the doctor contact me about the procedure being done. My response was, "we've already done that; I had a 45-minute conversation with the doctor about it about three weeks ago and while some of my concerns were addressed, many more red flags have appeared in the wake of that conversation." In short, I told her that I found the idea of saying that you perform a particular operation only to find out that it isn't really the surgery that was desired to be totally abhorrent; there is absolutely no reason for the deception, and it's totally unacceptable to dupe people into thinking that they're getting one thing when they're actually getting another.

She left me with a simple statement that said that in the event I change my mind, they will be happy to set up a new appointment, and that she would relay the concerns I had to the other staff and the doctor in question. My opinion on what will actually happen is that she might genuinely tell the surgeon about my concerns, but he'll brush them off.

So, now I'm (in some respects) back to square one.

 

[Larra]

Matt, you are doing a good job with your due diligence, and it's sad that so many other people don't. While we all complain about the state of medical care in our country, most people trust their own doctors, and certainly don't expect to be lied to as to what surgery is being performed.
What I suspect may happen now is that someone at the hospital where your surgeon operates will tell the concerned individual from your insurance company that your surgeon does "the DS" at their hospital, because hospital administrators and other ancillary staff won't realize that what the surgeon is called "the DS", isn't. And many of these people are not trained to read operative notes to look for the technical details of what was and wasn't actually done, not just the name of the operation the surgeon stated.
And this bit about using one code or the other is complete … well, bullshit (yes, Spiky Bugger I said that) because there is NO code for the SADI/SIPS thing. That's the whole reason surgeons are falsely using the DS code.
If I worked for your insurance company, with the alert you have given them, I would get some operative reports from their insured that have been covered with the DS code and have one of the docs on their staff review them. It would be fascinating to know what they find, and what they do about it.

 

[DianaCox]

“If someone were to go looking at the surgery report afterwards they could determine that the actual procedure done didn't match the insurance's definition of the procedure and that could touch off a whole laundry list of problems.”

I think this is a BIG deal. But I don’t know whether your self-funded plan is going to want to investigate it’s own hospitals and doctors for insurance fraud. I would persist in pressuring them to do so, because it will help you with your request/demand for coverage of an out of network procedure at in network coverage rates. I would pressure them to review the op reports from any of their in network surgeons who submitted claims for so-called DS procedures, and match them to the description of CPT 43845. If there are not two anastomoses, it’s fraud.

 

[Spiky Bugger]

Matt, you are doing a good job with your due diligence, and it's sad that so many other people don't. While we all complain about the state of medical care in our country, most people trust their own doctors, and certainly don't expect to be lied to as to what surgery is being performed.
What I suspect may happen now is that someone at the hospital where your surgeon operates will tell the concerned individual from your insurance company that your surgeon does "the DS" at their hospital, because hospital administrators and other ancillary staff won't realize that what the surgeon is called "the DS", isn't. And many of these people are not trained to read operative notes to look for the technical details of what was and wasn't actually done, not just the name of the operation the surgeon stated.
And this bit about using one code or the other is complete … well, bullshit (yes, Spiky Bugger I said that) because there is NO code for the SADI/SIPS thing. That's the whole reason surgeons are falsely using the DS code.
If I worked for your insurance company, with the alert you have given them, I would get some operative reports from their insured that have been covered with the DS code and have one of the docs on their staff review them. It would be fascinating to know what they find, and what they do about it.

There's a ghost writer involved somewhere in here, I'm sure.