United health Care - HCA (help for my mom)

[mike727]

So, I am trying to figure out what to do for my mom. She is finally getting ready in her mind to get the DS surgery and when we went to schedule her first appointment with Dr. Smith in Celebration, FL she was told she couldn't do the surgery there because HCA requires that the surgery be done in one of their facilities. She works for HCA, which I guess requires in network facilities. There has to be an exclusion to this if there's not an option to do the needed surgery in your area, right?

We have verified she is covered for the DS, but now we are at a standstill. The girl from the Doctors office wouldn't even schedule the consult, which I thought was a little wrong, but whatever.

My mom has a BMI of 57 and I think she is best suited for the DS for long term weight loss. I don't think there's really any other DS surgeons in Florida that I would trust to do it.

Does anyone have experience working with this... OR just in general how we start the appeal process? She is starting her 6 month diet (stupid I know) now, so we have time to do whatever needs to be done to get the coverage.

The crazy part is, if she could do the surgery at an HCA facility, her total bill would only be like $500. But, I'd rather her get the right surgery, instead of the cheap surgery.

 

[AtomicMelanie]

Is there another HCA hospital where she could travel to?

 

[mike727]

No the surgeon only works with Florida Hospital.

 

[AtomicMelanie]

Is she set on Dr. Smith, or would she consider another surgeon in Florida and would she be willing to travel? I met a lady who had it done at an HCA hospital in Jacksonville, FL

 

[mike727]

With her issues, we feel like Dr. Smith is the best option we have. She has a blood clotting disorder, so far travel is really tough.

 

[AtomicMelanie]

Oh, my goodness! I sure hope everything goes okay with your mom. Maybe with records showing her clotting disorder in support of her case, they could approve her surgery. I wonder if they would see her as an out of network patient? The copays may be higher, but at least it's still an option.

 

[DianaCox]

Get a copy of her Evidence of Coverage document. It's going to be tricky, because I'm assuming this is a self-funded plan, but there are often statements in the actual contract that say something like this (this is from my daughter's plan, which is an ACA Blue Shield PPO plan - she needs to see a specialist who is out-of-network on her plan, so we are going to see if we can force BS to pay it at in-network rates):

The Member should contact Member Services if the Member needs assistance locating a provider in the Member’s Service Area. The Plan will review and consider a Member’s request for services that cannot be reasonably obtained in network. If a Member’s request for services from a Non-Participating Provider or MHSA Non-Participating Provider is approved at an in-network benefit level, the Plan will pay for Covered Services at a Participating Provider level.​

 

[Larra]

Mike, I'm glad you are helping your mother. I have nothing to add to Diana's advice at this point, except to be very cautious about any other Fla surgeons, as from what I know Dr. Smith is the only one doing the DS, and others are saying they do the DS but doing SADI and calling it DS.

 

[mike727]

Thanks guys! @DianaCox I will start there. I tried to download her coverage document online, but they don't store it online. So she is asking for a copy from her HR person.

I guess my big question is what if they come back with, well just get the RNY at an HCA hospital. Is there a way to prove medical necessity for the DS over other WLS options?

And @Larra yes that is how I feel too. I did the research for my own surgery and Dr. Smith was the only one in the state that made any sense.

 

[Munchkin]

This is the way it always happens. You had the surgery, didn't die, and now the rest of the family is interested.

After I had mine, my sister followed, and my H.

Best of luck to your mom. Get that insurance info. Many times what they TELL you is not what's in the EOC. There is always a way to appeal!

 

[mike727]

Thanks @Munchkin I am always sort of the guinea pig of my family lol. My wife is getting the sleeve at the end of this month and my mom is pretty much on board now, though she has a few hesitations sometimes. Now if I could only get my sister on board. She just turned 30 and still wants to "try it on her own" first.

 

[southernlady]

Now if I could only get my sister on board. She just turned 30 and still wants to "try it on her own" first.

I have a sister approaching 40...and at 5'2", she is SMO. She has seen me be a success for 5 years...and still wants to do it herself, not thru surgery. She will be lucky to live past 50.

 

[DianaCox]

"Is there a way to prove medical necessity for the DS over other WLS options?"

Yes:

• DS is better for SMO - lots of evidence
• DS is better for T2D - lots of evidence
• DS is better for apnea - significant evidence
• DS has best long-term results, no matter WHAT starting BMI - lots of evidence
• DS is better if the patient has to take NSAIDs - relevant for RNY, not sleeve)
• DS is better if there is a family history of stomach cancer (can't scope the blind stomach - again, relevant for RNY, not sleeve)

In addition, the DS is a standard of care procedure, and the option to have DS over other standard of care procedures SHOULD be up to the patient and surgeon. It is inappropriate to not allow a standard of care procedure just because there is nobody in-network who can do it, or who can do it at an in-network hospital.

 

[mike727]

@DianaCox thanks so much for all that. We will use this as we go through the process.

 

[mike727]

My sister is stubborn, but I'm praying and hoping for the best with her. And for your sister too @southernlady