Turned in insurance info to Dr. Keshishian...

[DSRIGGS]

Thank you! I did check mine. Bariatric surgery and more importantly for me revision surgery. Submitted all of there pre requisites and now cross my fingers. My only fear is too low BMI. Dr K hopes the "letter of necessity" he writes will be enough.

Dumping is a medical condition so hopefully that works. FYI - my 22 year old son had debilitating gastroparesis with nausea all the time from food rotting in his gut from not emptying. Dr K proposed a rouxen y limb off the greater curvature of his stomach with a large anastomosis to basically gravity drain his stomach. Naturally a RnY is thought of as a weight loss surgery but Dr K bypassed hardly any small intestine just dumping it in right after the duodenum and he still had some food go out the pyloric route. In any case, even though we thought they might have denied calling it a weight loss surgery when he wasn't significantly overweight, he got approval for us. He did wonders for Cameron and fixed several other things for Cameron during that surgery.

I have no doubt he will get you approved as well.

BTW he also got me approved for my revision to my DS even though my original DS was 23 months earlier.

I am hopeful he will get your revision covered for you as it is a medical necessity. Best wishes

 

[CaraOC]

BCBS PPO means nothing...
Each BCBS is an individual company EVEN tho they may have BCBS in their name. So BCBS TN is a different company from BCBSNC.

Then add to the mix, employer. An employer is allowed to NOT pay for bariatric surgery for their employees.

Then there is the BCBS ACA plans, each state has a say in what has to be offered.

Add to that, regular PPO and REGIONAL PPO's.

That is why we tell people to look at THEIR OWN Evidence of Coverage document for their own policy regardless of the plan.

What do you mean an employer is not allowed to NOT cover bariatric surgery?? My employer had an exclusionary clause so I didn't even attempt that route. It did seem rather discriminatory to me. I wondered if next some employers would add exclusionary clause for breast cancer treatment? It's perfectly legal to discriminate against fat people still. Just doesn't feel right.

 

[southernlady]

What do you mean an employer is not allowed to NOT cover bariatric surgery?? My employer had an exclusionary clause so I didn't even attempt that route. It did seem rather discriminatory to me. I wondered if next some employers would add exclusionary clause for breast cancer treatment? It's perfectly legal to discriminate against fat people still. Just doesn't feel right.

Just that...an employer has the right to not cover bariatric surgery since it is an extra charge to their bottom line. They HAVE to offer options to lose weight but surgery is NOT one mandated. Hell, just having a PCP mention it and giving you a food plan is all many HAVE to do. Even if the food plan is bogus. As long as it's documented that the PCP has given you information, that is all that is mandated by the ACA guidelines.
https://www.healthcare.gov/blog/10-health-care-benefits-covered-in-the-health-insurance-marketplace/

1. Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.

https://www.healthcare.gov/preventive-care-adults/

Notice it NEVER mentions bariatric options just screening/counseling.

 

[DianaCox]

The ACA coverage is in some respects state-specific, in particular for bariatric surgery.

• The ACA plans in CA and some other states are mandated to cover bariatric surgery
• They are NOT required to cover bariatric surgery in other states
• https://asmbs.org/articles/american...f-obesity-treatment-under-affordable-care-act
  
  • "In the complaint, the groups say there is a significant disparity between the 27 ACA benchmark plans that deny or exclude coverage for bariatric surgery, and the major private and government health insurance plans that provide coverage. Medicare, 49 state Medicaid plans, the Federal Employees Health Plan, the majority of state health plans, and the majority of employer-based plans with 500 employees or more cover bariatric surgery.
    
    The groups cite that a qualified health plan under ACA may “not employ marketing practices or benefit designs that have the effect of discouraging the enrollment of such plan by individuals with significant health needs.” They say this is being done to individuals who have obesity. In addition, the ACA prohibits the denial of health care benefits on the basis of disability. The groups say severe obesity falls under the American Disabilities Act, as currently defined. Finally, the groups argue that “empirical research consistently demonstrates that obesity has a proportionally disparate adverse impact on women” in comparison to men, when it comes to hiring and earnings, and those with severe obesity who joined ACA qualified health plans within the last two years did so with obesity as a pre-existing condition."

Only certain kinds of plans have to comply with the ACA mandates:

• Self-funded plans don't even have to comply with their own state insurance mandates - just the bare-minimum standards of federal ERISA law
• Many regular fully-funded plans don't have to comply with them either, including ones which are "grandfathered" under arcane rules
• Large plans differ from small plans, and all differ depending on what state they're in.

So it is clear that there is NO consistency with which morbid obesity and bariatric surgery are treated as a disease/valid treatment. That needs to be fixed, but don't hold your breath.

 

[Melanie0574]

• Go to a pre-op appointment with an in-network bariatric surgeon, and request that you get a DS.

Working on step one. I have an appointment with Dr. Hanna (local surgeon) on April 9th. I know he only offers the lapband,and the sleeve,but I will request the DS.

 

[Kristaz]

Still waiting for the insurance company! I am so impatient... It has been 10 days! Is that normal?

 

[southernlady]

Still waiting for the insurance company! I am so impatient... It has been 10 days! Is that normal?

10 days or 10 business days? Remember, you have to count business days. However, it won't hurt to call and ask.

 

[Kristaz]

10 days or 10 business days? Remember, you have to count business days. However, it won't hurt to call and ask.

7 business days... I called DR office they hadn't heard anything. Can I call the insurance co direct?

 

[southernlady]

7 business days... I called DR office they hadn't heard anything. Can I call the insurance co direct?

Might wait til Monday...many businesses have today off.

 

[DSRIGGS]

7 business days... I called DR office they hadn't heard anything. Can I call the insurance co direct?

Sure you can and I would.

 

[Melanie0574]

@DianaCox I have my appt tomorrow with a local bariatric surgeon to start the steps you described,but I was talking to my Mom today about it,and she brought up a question that I thought I would ask you. The question was, if the DS surgeon of my choice does not accept my insurance,what good would it do to try to make my insurance pay for the surgery? If I go to Dr. K for a consult,and he writes me a letter to use in an appeal to my insurance,even if they agree to pay for my surgery, would Dr. K have to accept it? My appt. is at 1:00 so hopefully you will see this before then. Thank you in advance!

 

[DianaCox]

"Accepts your insurance" means he is contracted with your insurance company (in-network) and therefore obligated to accept whatever discounted rate the insurance company has decided he is going to get, and can't ask you to pay the difference between that amount and his normal charges - just whatever your copay is. That is what in-network means.

If he is out of network, he will still accept whatever crappy small amount of money your insurance company will pay him - which is even lower than the amount they would pay him if he was in network - but YOU are responsible for the difference between that amount and his normal fee.

Example: DrK's normal fee is say $15K. In-network reimbursement rate is 90% of discounted negotiated fee of $5K. Insco pays $4500; you pay $500. DrK cannot ask you for the other $10K.

Out of network reimbursement rate is 50% of discounted fee. Insco pays $2500; you owe DrK $12,500.

But the BIGGER issue to watch for us whether the hospital he uses is in-network. His fee is capped; the hospital bill can skyrocket with the slightest complication. Watch that the anesthesiologist is in-network too.

 

[DSRIGGS]

"Accepts your insurance" means he is contracted with your insurance company (in-network) and therefore obligated to accept whatever discounted rate the insurance company has decided he is going to get, and can't ask you to pay the difference between that amount and his normal charges - just whatever your copay is. That is what in-network means.

If he is out of network, he will still accept whatever crappy small amount of money your insurance company will pay him - which is even lower than the amount they would pay him if he was in network - but YOU are responsible for the difference between that amount and his normal fee.

Example: DrK's normal fee is say $15K. In-network reimbursement rate is 90% of discounted negotiated fee of $5K. Insco pays $4500; you pay $500. DrK cannot ask you for the other $10K.

Out of network reimbursement rate is 50% of discounted fee. Insco pays $2500; you owe DrK $12,500.

But the BIGGER issue to watch for us whether the hospital he uses is in-network. His fee is capped; the hospital bill can skyrocket with the slightest complication. Watch that the anesthesiologist is in-network too.

I have never had an issue with an anesthesiologist and shouldn't because as a patient contracting with a surgeon to do a procedure at a certain hospital, I don't have the ability to choose the anesthesiologist. The hospital contracts with the anesthesiologist and they pick that provider of services, not me. It is their B2B relationship, not mine so I let them hash that out. We have on occasion gotten a pathology bill or other ancillary services bill resulting from a hospital stay or procedure through a network provider. It typically goes away but we have on occasion had to call and explain that they contracted with the hospital and not me, so I owe them nothing (up to those two parties to work out their payments)

 

[Melanie0574]

Thank you for the clarification. @DSRIGGS I see that you had your surgery done with Dr. K, do you happen to know what insurances he accepts? I sent them a email,but haven't heard anything yet.

 

[DSRIGGS]

We

Thank you for the clarification. @DSRIGGS I see that you had your surgery done with Dr. K, do you happen to know what insurances he accepts? I sent them a email,but haven't heard anything yet.

We have BCBS PPO so that is all I know about. His site might list it.