Scheduled consult with Dr. Ayoola

[Sunshine Too]

Its been a while since I posted anything, but my journey towards DS continues. I have a consult scheduled with Dr. Ayoola on January 15th. The following is my list of issues/questions to discuss with him and his staff. Any thoughts or comments are appreciated.

One side note which I will post more details about later. I have United Healthcare. Nowhere in my Summary Plan Description OR the United Healthcare Policy On Bariatric Surgery does it mention anything about a dollar cap on what they will pay. But when Dr. Ayoola's staff called to preverify, they were told by United that there is a $15,000 cap on what United will pay. I subsequently called United and after much digging was told that there was a $15,000 cap that was contained in a super secret internal document that he was not allowed to send me a copy of. This raised big red flags for me. How can I be in the insured party and there is a document which spells out the amount of my available benefit, but they wont' give me a copy of it? Furthermore, how can they say they cover DS with only $15,000? From my research, there isn't a surgeon/hospital in the US that would do it for that price. I'm going to request Dr. Ayoola's staff to give me a written copy of anything they received in writing from United. I may need some help from the insurance gurus including Diana. For now I just wanted to mention it since the $15,000 cap is referenced in my list of questions below.

DR. AYOOLA QUESTIONS

Review my medical history, reasons for wanting DS.
What is your experience with DS with lightweight patients?
Does DS sound like a good fit for me?
Do you perform laparoscopically? Robotic?
Any reasons why surgery would be unable to be completed?
How many complications do you see? What type?
How many people die from surgery? Primary cause?
What size stomach/bougie? How determined?
How are bowel lengths (common, alimentary, biliopancreatic) determined: Hess, fixed length?
Do you perform leak test during surgery or post-op?
Do you remove gallbladder? Included in surgery price?
Do you remove appendix? Included in surgery price?
Do you perform liver biopsy? Included in surgery price?
I prefer Baylor Trophy Club hospital. Do you have preference? Same facilities?
Insurance requires 6 month diet. How do you coordinate with PCP?
What is your pre-op diet requirement?
Post surgery labs. How do you coordinate with PCP?
Is your nutritionist knowledgeable about DS?


GOALS

Eliminate high blood pressure, high cholesterol, pre diabetes, possibly sleep apnea.
Currently 268 lb = 38.4 BMI
Low point goal 153 lb = 22 BMI (loss of 115 lb or 43%)
Regain 20% of 115 lb (23 lb): 176 lb = 25.3 BMI
Is this realistic?


STAFF/INSURANCE

Request copy of any documentation received from United.
Have/will you verify that hospital and anesthesiologist are covered in network?
Given $15,000 cap from United, what would all-in cost be for me?
Does cost differ from one hospital to another (Presbyterian Flower Mound vs. Baylor Trophy Club)?
What is included? After care? For how long?
Do you offer complication insurance? What does it cover? Cost?
Will you require a deposit? How much? When due?

 

[southernlady]

One side note which I will post more details about later. I have United Healthcare. Nowhere in my Summary Plan Description of the United Healthcare Policy On Bariatric Surgery does it mention anything about a dollar cap on what they will pay. But when Dr. Ayoola's staff called to preverify, they were told by United that there is a $15,000 cap on what United will pay. I subsequently called United and after much digging was told that there was a $15,000 cap that was contained in a super secret internal document that he was not allowed to send me a copy of. This raised big red flags for me. How can I be in the insured party and there is a document which spells out the amount of my available benefit, but they wont' give me a copy of it? Furthermore, how can they say they cover DS with only $15,000? From my research, there isn't a surgeon/hospital in the US that would do it for that price. I'm going to request Dr. Ayoola's staff to give me a written copy of anything they received in writing from United.

Regardless of what the SURGEON'S office says, the final say IS your policy.

I will say this...regardless of what the surgeon and hospital charge, UHC will ONLY pay what is "customary" for a procedure which is NOTHING close to what the surgeon/hospital sends to the insurance company as the bill.

I had surgery in Jan 2011. Dr. Boyce submitted a charge for surgery of $15,000. BCBSTN Medicare was my insurance company (and dh had UHC at the same time and I saw his EOB as well). Of the $15k submitted, the insurance company ONLY paid $1845.90. The rest is considered "network savings" and I was not responsible for that part. I owed ZERO. So while he charged 15K, he was only paid 1,845.90 for my surgery. I don't have copies of my dh's EOB's right off hand but his was about the same.

While the total for my surgery charged to the insurance company was close to 60K for everything, I paid $285 my hospital copay, my copays for each visit, AND the program fee charged by my surgeon. EVERYTHING else was paid MINUS the "network savings" for using an in network surgeon/facility. As I mentioned, the surgeon got less than 2K out of the 15K, and the hospital got less than 4K for the about 45K they submitted to the insurance. So my 60K surgery actually cost less than 6K as paid by the insurance company.

 

[Larra]

I hope @DianaCox sees this stuff about the super secret cap on what they will pay. What I will say is that this is a huge red flag that you MUST document every single contact with your insurer because things could get sticky. This means of course save all correspondence and emails, and also document every phone contact including name and job title of the person you speak with, their phone number, date, time, and summary of conversation. If they refuse to provide a name, document that. If you can't get answers from them, request to speak with a supervisor and document if they refuse that. You get the idea. You are creating a paper trail in case you need to take your case to whatever agency governs insurance companies in your state.
Additionally, you are, to my understanding (I'm not an attorney) legally entitled to a copy of your policy, and I would think that this would preclude any "secret" elements of your policy. Also, if your policy is governed by the ACA (affordable care act, aka Obamacare), dollar caps on care for a given medical problem are now illegal.

As far as your questions, I think you have it more than covered.

 

[Sunshine Too]

Larra, you're thinking along the same lines I was. I can't see how there is a document that limits how much they will pay, but I (as the insured) am not entitled to a copy of that document. We are keeping written records of each contact we have.

southernlady, I will be interested to see what Ayoola's office has to tell me about costs when I visit. I checked myself and both he and the hospital are listed as in network with United. So if it works like every other in network service, then doctor and hospital have already agreed to a discounted price with United (just like you describe), and all I owe is 10% coinsurance up to my max out of pocket for the year. I understand there may also be a "program fee" or the like for some of the followup with nutritionist, although I'm wondering if United may cover some of that also.

My consult is next Friday, so I will know more after that.

 

[Sunshine Too]

The insurance clusterfuck continues. We called company HR to request a copy of the "Evidence of Coverage". HR said that I would have to obtain that from United. So we called United and the rep had never heard of the EOC before. Kept putting on hold and after speaking with a supervisor they claimed what I was talking about was a "Proof of Credible Coverage" and that there was another department at United (Clinical Services Department) that was responsible for pre-authorizations that would handle that. They also indicated that this "Proof of Credible Coverage" document was short and not anywhere near the 50-100 pages or more that I have heard referenced for the EOC.

I subsequently got a voicemail back saying that the regular rep had contacted the pre-authorizations department and that since my doctor had not yet submitted a request for the procedure, that there was no "Proof of Credible Coverage" yet and they could not send me anything. So it sounds like the "Proof of Credible Coverage" they are talking about is not the same as the "Evidence of Coverage". Is there another name that the EOC might go by? It seems ridiculous that its so difficult just to get a copy of the policy I am paying for. When you buy auto insurance, life insurance, homeowners insurance - they automatically send you a copy of the full policy.

The regular rep also read again to me the language about the $15,000 cap. We again asked for a copy of that document and the rep said that the information about the $15,000 was "printed in red" on the document she was reading which means it is "secure information" that cannot be sent to a policy holder.

All of that said, I again verified that surgeon and hospital are both in network. So going back to Southernlady's comments about how "normal" in network procedures work, shouldn't the $15,000 cap be irrelevant since United and the surgeon and hospital have agreed to a contract price (possibly less than the $15,000 total) and since its in network I am not responsible for the balance?

To be clear, I still don't have a quote from Ayoola on how much my out of pocket would be. I just want to be armed with as much information when I see him next week so that I can talk knowledgeably with the staff. Thanks again to all those who take time to reply and assist the newbies. There's a special place for you in heaven, just as there is a special place for most insurance companies in hell.

 

[Clematis]

I am holding Anthem's in my hand and the mailing cover says "A Guide to Your Benefits", the inside cover says "Your Health Certificate", and the body copy starts "Health Certificate of Coverage herein called The Certificate. This certificate is the legal document explaining your coverage." Maybe some of these terms may help. When I asked my husband's HR, they had no idea what this was. When I called Anthem, they too had no idea what this was. I found a link on the "My Anthem" website to receive this, or rather they sent a certificate that my husband had to sign (which I signed), and then returned to them. It took 2 months to actually receive the thing. It is 117 pages.

 

[Larra]

I've never heard of a "proof of credible coverage" before, though clearly such a thing exists as the rep saw it. But I've also never heard that you can't get documentation of your coverage until you apply for preauthorization for some kind of care. I share your point of view that this is your policy, just like your care insurance policy, only longer and more complicated.
Good for you for documenting all conversations! We've seen this come on handy later in the game.
I guess I would call HR again and tell them you are unable to get your EOC from United and get them to help you. Talk to a supervisor if needed. And document all contacts with HR as well. Keep going up the chain of command as needed. You are entitled to this document, and often, when there is a denial, the info and language in that document makes all the difference.

 

[DianaCox]

Call your state Department of Insurance and talk to someone there - you may have to file a state grievance to get it.

Also, find out if your plan is fully funded or self-funded - it makes a HUGE difference in what the employer and insurance company is allowed to do. Also ask if the plan is grandfathered or not - that would exclude it from some or all of the ACA requirements. But I DON'T believe they can withhold a copy of your insurance contract from you, and your HR department should have it. You many need to speak to the VP of HR to get it.

 

[Clematis]

What about calling United's legal department and asking for the legal document explaining your coverage?

 

[southernlady]

When we were covered BY UHC thru GE, we got a huge book (bound and about 80-100 pages) every year after open enrollment in Oct from the HR dept detailing our benefits, etc. It was THIS document we toted off to the surgeon's office so they could COPY (while we watched) the part that gave dh the right to bariatric surgery WITHOUT going thru the 6 month diet. All they required for OUR plan was 5 years of morbid obesity. And OUR plan overrode anything UHC put out generally. GE is a big enough company to do that.

It was the 5 years of morbid obesity that kept me from using UHC but thankfully I also had (as my secondary), a Medicare Advantage plan that covered mine with NO hassles.