Insurance & Financing

I have an appt to see the surgeon before the end of the month but already insurance questions are coming up. I have an out-of-network doctor and hospital. What does tricare actually pay for after they have approved you? I know that the "allowable" charge is ridiculously low (a little over $1,000). This is for the lapband alone, the hospital charges, ie. anesthesia etc. are separate). Will they cover 75% percent of that that allowed amount or the amount my doctor charges. My doctors fee for the lapband alone is $10,000. I just need to know if they will pay 75% of that or the allowable charge. I'm beginning to sad because I won't be able to afford that. No MTFs in …

I had my sleeve done on May 19th of this year. My insurance pre-approved the procedure and the hiatal hernia repair. Today I got a bill from my doctor. The bill stated that the insurance company had paid zero and that I owed the doc $60,000. Oh my!

What if you had the lap band done under another insurance, they paid to take it out (due to slippage) and now you have new insurance (Wellmark). What's the chances of having to meet the criteria for weight loss surgery all over again? UGH!!! I did that once and now have to jump all through the hoops again to get a revision. ARGH!!!!! This is so frustrating!!!!!!!

I am a month into the six month physician supervised weight loss program. However, I am afraid that when I'm done the surgery won't be approved because I have no weight history. I guess I am disgustingly healthy for a fat person, or just don't go to the Dr when I should. Anyway, I had to have a tetanus booster last year and that's it. My youngest boy is almost six so my pre-pregnancy weight from that would have been almost seven years ago, and I was obese then. Will this be good enough? Anyone have any experience with this? That's what I get for not costing the insurance company enough money up until now, I guess.

Anyone know anything about Wellmark/BCBS in Iowa and where they are as far as covering the sleeve? I heard that it was in committee. It seems that BCBS in other states is covering.....

The problem is this...I made several calls to our Insurance company to let them know I was having LAP-BAND® surgery and the person said it was covered. Well, I didn't believe them. I figured the person was new, or didn't know what LAP-BAND® surgery was, so I called again a few days later to get a new person and ask the same questions. This person too said, "yes, this surgery is covered" This person was even more helpful giving the link for the pre-surgery requirements all of which I met except for the psych eval. They even gave me the link to print out the form to file with the insurance company since the doc I was using did not file with insurance and wasn't in the Blue …

Hi Everyone, I was just wondering if anyone else was thinking about what kind of changes we might see in 2010 to the requirements for surgery. Higher BMI numbers, longer/shorter diet requirement, longer period for proof of obesity, etc. With all the talk on tv about health coverage, does anyone think that independent insurance companies will make their requirements harder so fewer people qualify just so they don't have to cover as many people. Any thoughts from anyone? Cathy

I am new to the forum! I have been reading over so many of your posts and everyone is so informative! Thanks so much! I have been looking into getting the lap band for a while now and my insurance would not cover it or any WLS. Now, I know that it was a blessing in disguise because I likely would have regretted the lap band with all the complications. Anyway, this year our insurance began covering WLS (Aetna)! I was so excited and finally got the nerve up to schedule an appointment a couple of weeks ago and went in with full intentions of the lap band. My Doctor pretty much talked me out of it! He is all for the sleeve. After much research, I am very sure that the sleev…

If your insurance paid, do you know how much they paid for the procedure. I know it will vary by location, plan etc, but I am just trying to get an idea of how much the insurance companies are actually paying for the procedure. If it is less than what I am paying self-pay, then maybe I can persuade my physician to give me a better deal. If I pay up front why shouldn't I get the same rate as an insurance company? They don't have to file the claim, wait for the money, appeal if denied, etc...

:biggrin: I guess I don't quite understand this, but apparently my insurance only covers $1000.00 dollars on any surgery! Does anyone know anything about this, it just seems very, very low for surgery coverage, I pay more in one year for health insurance than they do for a surgery, does this make sense to anyone. I would love to hear from anyone out there if they know anything about this. God forbid if I had to have a emergency surgery, my insurance would do absolutley no good, I would still end up with a very large bill, I thought the purpose of insurance was to save people from paying high medical bills! Am I the only one confused by this? Please someone help me under…

Can anyone tell me where online I can check for Tricare Prime approval?

Hello everyone! I am a confused newbie who has found herself here! In pursuit of a gastric bypass, I have recently completed my insurance company's required 6 month supervised diet, meeting all of the criteria for an "easy approval". I have a well qualified surgeon at a bariatric Center of Excellence in the Chicagoland area, but much to my surprise, I was disapproved within two days of my paperwork being submitted due to an error in the process. The situation was rectified and my paperwork was resubmitted 5 days later. That has been over a week ago, and I'm becoming a frantic mess! In the meanwhile, I am a firm believer that everything happens for a reason, and there are…

So I just went to my lap band consult appt last Thursday and they said I qualify. I'm much too impatient to do the 6-month option Aetna has so I want to go with the 3 month one (requirements pasted below). My surgeon's office has something in place for the 6 month route but they can't tell me anything about the fast track one and what I should do. I tried finding a different doc in my area that might but no such luck. If anyone using Aetna EPO has been approved for lap band using the 3 month option, PLEASE tell me how you did it. Mainly the exercise regimen (Excluding a personal trainer as that is too expensive) Multidisciplinary surgical preparatory regimen: Proximat…

I went to my Humana web site which said I was approved May 13th and this expires 6-15-2010. I have yet to hear from my surgeon's office though. How long should I give them?

Good Morning, Has anyone had any experience with BC/BS of Ohio PPO for Verizon Retirees? I was recently denied by them on the basis that I need a BMI of 40 or greater (mine is 36). Anthem only administers this self insured plan for Verizon. However, all the access materials to the benefits say a BMI of 35 to 39 is OK with comorbidities (sp?) which I have. I now have a Verizon Benefits Advocate helping me to get the actual benefit in writing but it's taking forever! BTW, an E-mail I sent from the "Anthem for Verizon website" in 2/2010 to verify my benefit was responded to me as needing a BMI of 35-39 w/comorbidities or 40+ w/o any so I was given wrong info to begin w…

Hi everyone, I am in the process of figuring out whether the SRC insurance I have will cover part of the cost for the sleeve and if they will, what my out-of-pocket expenses will be. The hospital doesn't seem to be able to give me any idea what they would bill the insurance company, so it is impossible for me to get an idea. Also, I would like to know so that if my cost is too high, I can make plans to go to Mexico and have it done. I know that every hospital is different and costs can vary widely. But - can anyone let me know what your hospital was billed? I don't care what your insurance paid because mine is different, but if I can get an approximate (maybe high…

Okay, I am so frustrated. Today I had a big let down. I called my insurance company's Bariatric Resource Center to find out that Morbid Obeasity surgey or programs were not covered under my benefits... This was a huge let down only after feeling euphoria on Wed. when my PCP said that he would refer to a bariatric surgeon and that I was a good candidate for the procedure... Can anyone help me? Please! This surgery is of most importance, but I just cannot afford to pay for it out of pocket. Danielle:ohmy:

I have a dilemma. I have a limited benefits insurance company that I am going to use for sleeve WLS. It has caps on the amounts it will pay for certain hospital charges, etc. Going round and round with the insurance company and hospital has pretty much gotten me nowhere since no one wants to commit to an amount. I can understand that, but I also need to know what I might possibly be looking at in terms of what this is going to cost me out of pocket. If anyone has an itemized bill for their surgery and would be willing to share the information with me, I would really appreciate it. I know how much the surgeon will cost; it is the hospital charges I need to know. Fo…

All of my stuff was submmitted back on March 25th. My ins confirmed to me they received everything on April 1st. I waited about 3 weeks and called.They said it takes 30 to 45 days to decide. So i waited 2 more weeks and called back. The next person said it takes 45 days and its still in review. By now its May 12 and my Dr. office called to tell me they couldn't get a live person and had me call again.I did and yet again I got the same thing but this time my ins told me they will put an expadite status on it. I called my Dr. office and told them. She told me to check back this week. I called yesterday and once again got the "in review"status and was also told its going to …

Has anyone else used federal bcbs? I have heard it pays well, What were out of pocket costs and the procedures for approval? Any info would be appreciated, I go to seminar on April 29th in Jonesboro, Ar and would love to know some things before I go.

http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0051_coveragepositioncriteria_bariatric_surgery.pdf

Hi, my name is Nicole and I am wanting to get the Lap Band. I am 5'5'' , 280 lbs., and 22 years old. I have been overweight my entire life. I was on Medicaid but now that my income exceeds guidelines I was dropped. I started my job in March and plan to get insurance through them. They offer BC/BS (IL). I know they cover the surgery but I am not eligible for insurance for another month. (Three month wait) My question is if there is a certain amount of time I have to be insured to get the surgery? I plan to ask as soon as I am eligible but would like to get a heads up. I am so excited to get the surgery but there is already a 6 month wait and I don't want to have to wait mo…

I have had a carecredit account for awhile now since my lasik surgery. I have absolutely LOVEd this company and would prefer to stick with them through the lapband journey. Does anyone in Colorado know which companies accept it? Ifele bad calling each office and wasting their time when my first question is about the financing....:thumbup:

well today I have been told by my insurance co Anthem BCBS that I have been denied b/c sleeve is 'not medically necessary' which is confusing to me b/c I am 100 pounds overweight, BMI 41 and being treated for high blood pressure. When I spoke to BCBS, they told me that my provider should contact them for more information on the 'not medically necessary', that right now there was nothing more that I can/should submit. Ok but I know I've read on here how ppl submit letters of appeal!! I'm so confused, SOO depressed~ I have tried to have positive thoughts all this time just to be let down. Please give me any help you may have, including letters of appeal! I will fight for o…

Hi there, I've recently been accepted into the Kaiser weigh loss program. I know that this program will take some time before surgery (up to a year, I understand) and i'm okay with that... here are my questions: So far, Ive found that the Pacific North West Kaiser does not do the lap band (I dont want that anyway) and they focus on the bypass surgery. I, after doing my research, want the sleeve. So much so that - rather than have the bypass - i'll private pay the sleeve. I'd rather have my insurance help. I'm wondering if anyone has had the sleeve through Kaiser PNW? Also, I have PCOS and bone on bone in one knee - and i'm only 32. I'm wondering if people …

10 required letters

Hi there, it's been a while since I've been on the board, I've been a busy bee, doing all the requirements for the sleeve surgery- nutritionist, classes, homework, lab tests, physical, psychologist evaluation- all came out good and ready to go, only problem is I have been DENIED the surgery due to Blue Cross Anthem states it is "investigational"! I am heartbroken, but I won't give up. I am determined to fight this all the way to the state level. I believe in my doctors at UCLA and my previous surgeons Dr.Francis and Dr. Leport, as well as my primary care doctor, who has known me for over 10 years, when they tell me that this tool will work for me! I am beginning my resear…

I work for my local school system and have BC/BS. The system is "self-pay". I found out that WLS for morbid obesity is covered. Yesterday I talked with 2 customer reps and the Finance Counselor for the weight loss surgery center I've chosen. I got the code for VSG surgery (43775). The ins. rep told me that VSG is mentioned along with all the other WLS (he named them all) and there was nothing that said VSG was investigational. I'm going to the Surgery Center's seminar for potential surgical candidates on May 17th. This is required to get a consulation appt with the surgeon. HOOP # 1. I am so determined to have this surgery and not to opt out for the lap band or RNY…

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So Tricare is being difficult and hubby is sweating bullets. The doctor's office is confused because they say Tricare is not being consistent and using outdated regulations. I have to go in and get measured. Hubby wants to know if anyone has appealed a denial to Tricare and been approved and if they have a copy of their appeal letter.

Aetna still considers the LapBand "investigational/experimental" and excludes it completely on a company level. I have never yet heard of any cases where Aetna paid of its own accord, so unless or until Aetna changes its policy on the band being investigational the best bet is to see if you have an external appeal provision in your state. I did, and I won! Here's how it went: The State of New Jersey, like many other states, provides for a third-party review of insurance carriers' decisions. That means there might be a law in your state that provides you with the right of EXTERNAL review if you have exhausted your company's appeal process and lost. In my case, I took …

I went to my MPF in January to start the process of getting banded. I have since seen the nutritionist and the psychologist but I have had a lot of other things going on and I have not had time to get my form from the MPF for Tricare approval. How long do I have before I have to start the process over again?

Has anyone with tricare been banded in one region and then moved to another region? How hard was it to get your referrals for your fills. I was banded under tricare south and now am in triwest. They denied my fills b/c my new doctor office did not send in all the necessary info about my surgery. I in return appealed and faxed in 32 pages of info(beginning with my preassessment). This should change b/c I am only needing to be under doctors care. What do you think?

Are there any companies out there giving medical loans right now?

I've got UHC and they're covering 80%... anyone else have the same coverage? How much did you end up having to pay out of pocket? How much was due before surgery and how much after?

My Band Slipped in April. I had to get Rebanded. I was so sick that I went to the ER and was told I needed Emergency Surgery to fix the Band or Remove it completely. The doctor fixed it. So I still have a Band. One month later I just got my Insurance Explanation of Benefits where they only paid the surgeon a portion of the surgery and they are saying I owe the doctor 18,000. Could this be possible. On the Insurance paperwork they say my Surgery was not Medically Necessary. Hello I couldn't eat or drink for more than 4 days. I was completely dehydrated & I thought the surgery was most definitely medically Necessary. No one told me when I had surgery that I wou…

Hey Everyone, I have bluecaid in Michigan, can only use it in Wayne, Livingston, and Washtenaw Counties, If i show "need" for this, would they pay for it? full or half?

I went to the lap band surgeon Friday 5/1/10 and they said everything looked good for surgery and they would submit the letter. So, of course every day since then I've been checking the website to see if the letter had been submitted. Yesterday, still nothing showing in my authorizations. So I checked today and there's my authorization request with an "A" by the status. So I click to look and at the top it has a case/order number and under that case category APPROVED!!!! Is this for real? Has anyone had this happen before? Your authorization goes from not even showing to approved in 1 day, skipping right over pending? Or does the approved mean something else, lik…

Has anyone been approved with BMI/weight alone? I have SEVER back and hip pain and am only 20 years old. I'm hoping to get surgery but now I'm starting to get very very worried. They said I need BOTH weight of the 100lbs over and a whole long list of things. And I haven't had my physical yet but I don't think I have any of the other requirements. So, Has anyone been approved w/ BMI/weight alone and how long did it take?

On 6/18/2009 I called my insurance and was told that the lap band was covered, she even walked me through finding the papers to print out about it. I went through all the hoops of a six month diet and everything, had all my papers filled out and was ready for my surgery. The lap band doctor turned in all my papers to the insurance for approval and it came back denied and said that they didn't cover it. I called up my insurance again today and the lady looked back through my files and said that it was never covered and she could see when I made the phone call on 6/18/2009 and she could see that the lady told me that I was covered. But all she said that I could do was m…

I finally had my official first consult with my Dr. last week, and talked with the insurance liasion about a week before that. Both are saying that Aetna has gotten very strict about the 2 year history. I've decided to do the 3-month program, much of which I have to pay for out of pocket. My Dr. warned me, though, that Aetna may still not approve me because of the lack of history. I am going to try putting together a photo portfolio and essay like I read here that some others have done. My BMI is over 42, I don't have any co-morbidities, and the only medical history I have is last year's physical, which has me at just under 40 BMI. I also can get my kids' …

So, I have been lurking the boards reading as much info as I can and reading up on Tricare policies prior to approaching my PCM. One thing I keep seeing is talk about co-morbidities and I was wondering if this is the same as the 3 additional requirements for Tricare approval if you are only 100 pounds over weight? I need this surgery but I am not sure where to begin and scared of denial. I cannot even get Tricare approval my thyroid medication anymore! (brand name vs generic). I am 29 years old. I see a neurologist, an endocrinologist, a gastroenterologist, and I am on a wait list for the rheumatologist I want to see. I am also under the care of my OBGYN because I am…

How long does it take for insurance to let you know if you are approved or not?

is there any self payers in DE, MD, PA, or NJ area'sif so who did you use and what did it cost. thnks

This is a quote from a ASMBS report regarding Aetna and UHC beginning to cover the VSG. They are hopeful that other insurance carriers will follow suit soon. "We are pleased that Aetna and United Healthcare now includes sleeve gastrectomy among its covered bariatric procedures," said John W. Baker, MD, FACS, President of ASMBS. "In the rapidly changing field of bariatric and metabolic surgery, it is important to provide coverage and access to a wide range of proven treatment methods. Sleeve gastrectomy has now reached that threshold where the data and our experience with the procedure supports its safe and effective use in people affected by the chronic disease of morb…

I have been reading here and there that Medicare is going to cover the sleeve in 2010. Has anyone else heard that? I called Medicare and the representatives only know about what has already been approved. My surgeon's office doesn't know anything. My surgery is scheduled for December and I am willing to put it off until early next year of course if Medicare will cover it. Does anyone know how to find this information out? Thanks so much for your time. Pennie

Hi. I am wondering if there is anyone who has had the surgery done by the Veterans Administration Hospital system. In particular Pittisburg Pa. If so what was the experience like and what did they want you to do?

I have Carefirst BCBS PPO but supposedly I do not have WLS option on my policy therefore lapband is not even an option. Seems to me there should be a work around not having the WLS option on policy. I called them and asked if I weighed 1500lbs, would you pay for surgery or just continue to pay $600 a month for pills, year after year.....Guess what...they just wont pay for WLS without having WLS option on ones policy....anyone know workarounds for this? I meet all the criteria..BMI, sleep apena, diabetic, hpertension etc...

I have Blue Shield EPO in the Central Valley CA area. Just wondering if anyone else has gotten the band done with this insurance. I am told that I only need three things to get approval. I need to meet with a PCP, psych and dietician. I have meet with everything but the dietician. I meet with her in 2 weeks. Just wondering if after all is complete how long the process to get approval was frmo someone with the same type of coverage. Thanks.

My insurance requires a medical necessity letter from my doctor. Can someone share what their doctor wrote? Does he need to go into major description on why that I need a Sleeve? Thank you tim