allycatt98

MsJoy, You need to review your policy to determine both your deductible and MOOP (Maximum Out-of-Pocket). Typically the surgeon will request their fees up front. They will be able to tell you based upon their contract with your insurance how much that will be. I'm going to give you a general scenario, you will need to change the numbers to reflect your plan. Deductible $3000. MOOP $6000. Co-insurance 20%. Remaining Deductible $2914 Office visits $140 - Surgeon Office visit - Behavioral Health consult - $140 Surgery cost $2400 - Surgeon Surgery cost $10,000 - Hospital Pre-clearance testing - $500 Now because my deductible hasn't been met, the costs of the consults and any pre-clearance requirements (i.e. X-rays, ultrasounds, EKGs, EGDs, etc.) are my responsibility. The costs paid count towards my deductible. Once I've reached my deductible, the insurance will pay 80% of costs until I reach my MOOP. Once I reach my MOOP, then remaining COVERED costs will be paid at 100%. This is why it's very important that you know these amounts. So after paying for my pre-op testing and consults, I have only $2134 left remaining towards my deductible ($2914 - $780). The surgeon will collect their $2400 fee from me prior to surgery thus bringing my deductible down to $0. My MOOP has also been reduced by $266 bringing the remaining balance to $2734. My insurance will now kick-in 80% of my hospital costs. I am responsible for 20% of costs up to my remaining MOOP balance of $2734. So the insurance pays $8000 (80% of $10,000) and then I'm responsible for the remaining $2000. I still have not met my MOOP yet, so I will be responsible for paying for any additional medical treatment that year up to $266. Again, these are only estimates just to give you an idea of the process. Your amounts will differ, but the process is the same. Keep in mind, the billed rates are always more than what the actual insurance company pays anyway. You are only responsible for the negotiated rates if you're going to an in-network provider. That's the perk of staying in-network. Since amounts that will be given to you by the hospital and surgeon are only estimates, it's important that you keep track of costs by reviewing ALL of your EOB statements from your insurance company. They will detail what was billed, if it was covered, the negotiated amount, the amount paid by insurance and your responsibility. Because there are a lot of moving parts involved with surgical estimates the amounts can and often do change. Additional tests and procedures will reduce the remaining amount of your deductible thereby also reducing your out-of-pocket to the surgeon and hospital. In regards to the hospital, it is important that you know how to negotiate. Remember, claims aren't aren't necessarily sent automatically. So it's possible that your deductible might not reflect your actual amount remaining because the imaging center hasn't submitted a claim, etc. the hospital will always try to collect any remaining deductible and a portion of your co-pay. When you register for your surgery and meet with the financial counselor you should have all of your paperwork with you -- especially if your remaining amounts aren't updated online yet. Remember, that's all they have to work with. They can't tell that you already paid the surgeon or that the claim for your EGD hasn't been received yet. Try to negotiate to pay at least half of your remaining balance (unless you're prepared to pay the entire balance) and set-up a payment plan you can afford for the rest. Does this help? I know it's probably more than what you're looking for, but I figured it might help. Let me know if you have any questions. Ally

I know you're in Cali, but still.... It's like the surgeon wanted to get paid twice! That even more than the typical insurance reimbursement. I would've run from that office screaming while clutching my purse tightly to my person. Ally

Kisha you're absolutely right. I could tell you stories that would make your hair stand on end. People unfortunately assume that there are safeguards in place to protect you in the States, but that's not always the case. Just take a peek in any nursing home and you'll see what I mean. So medical care in Mexico isn't really scary to me. My situation is a bit different though. I don't mind waiting six months to complete the nutrition classes and psych eval. I think it will better prepare me for the future and help me decide that this is what I really want. But, that being said the $6000 MOOP has my head spinning. Surgery in Mexico (even with travel expenses) would still be much, much less. The problem is that you end up paying for everything (all the little extras) when you opt for MX. I was told that a Cholecystectomy would be an extra $1000. I already have gallstones... So it's becoming less likely that I will be going to MX unfortunately. By the time all the costs are added up, MX isn't so affordable after all. So right now I'm in the process of working out a payment plan (or even possibly reduced costs) with the hospital since I will have to pay the surgeon's costs up front. Ally

Doubtful Sarah.... This is guaranteed cash money for them as I'm willing to bet your fee is non-refundable too. Program Fees aren't typically covered by insurance as they don't reflect a billable medical service.

I'm lurking on both the June and July boards. I will finish my nutritional counseling late June. So my surgery date will probably be in July. I go for my second visit on Thursday. Now I just need to find a doc.

I will finish my six months of nutritional counseling in June as well. I'm planning on a July surgery after we return from vacation in Alaska. I'm still debating surgery in Mexico vs. stateside.

Love it! I feel the same way, but these Florida docs are a bit cray-cray. Program fees have become the norm in this area. I would feel a whole lot better about them if they actually had some substance. Alyson

Hey Curvy, The letter from my PCP isn't a requirement for me -- thank goodness. I don't know why they make people do that. The reviewers don't even pay attention to it unless it is part of an appeal. I also don't have the telephonic coach requirement either. But, I have to go to a UHC Bariatric Center of Excellence which is causing most of my angst. There are tons of Centers of Excellence in the Tampa Bay area, but only one of them is considered a UHC Bariatric Center of Excellence. Argh.... I'm okay with the NUT counseling and psych eval. I feel like those requirements are beneficial and will help get me on the road to "wellness." I actually had my first "Healthyroads" weight mgmt. coach call two weeks ago. It was..... interesting. Ally

Grandma, What were your thoughts about Dr. Jawad? I felt that his practice was a bit "shady." If you make an appointment directly with their office, they schedule you for an initial consultation that consists of a group session, consult with the doc and insurance review with the coordinator. The paperwork includes an acknowledgement that they are going to bill your insurance for the group session (Physician Education) and if it is not covered by your insurance, you are responsible for the $200-$250 fee. The information provided/discussed during the group session is the same info reviewed during the free information sessions at the hospital. Based upon this, I decided not to go with Jawad. I'm curious to find out about your experience.

Hi Curvy, I posted about my fee a couple of weeks ago. I'm in Florida and the surgeon is charging $600... Personally I agree that it is an immediate way to secure non-refundable cash. This "Program Fee," covers 30 days of Vitamins, concierge services (like I can't book my own hotel room), access to a multidisciplinary team (but in actuality doesn't include mandatory nutritional counseling, or the psych eval, just the post-op Nut visit), support group (I live three hours away and think paying for an online support group is ridiculous) and educational material (guess they've forgotten about the internet). I'm disgusted at this point because the offerings in Florida are slim if I go thru insurance (UHC) due to the requirements of the Bariatric Resource Program purchased by my employer. I'm seriously considering Mexico at this point. Ally What part of florida are you in, I'm in miami, my program feed was $240. Hey Sweet, I'm in Tampa. There are only three facilities nearby (within 2 hours) that I can go to: Tampa General, Orlando Regional and Ocala Regional.

Hey allycatt98, Yes, my friend went through a coordinator named Cathy. My friend will not recommend her surgeon to anyone now. She saw everything I received as a patient from A Lighter Me and recommends them and Dr Ortiz to her friends. By the way, the owner of the hospital is an Internist named Dr Sammy Tepperman. He does not do the surgeries himself. But when he has a patient that needs it, he refers them to Dr Ortiz out of all the drs that perform bariatric surgery there. Dr Ortiz operated on one of Dr Teppermans's patients while I was there. I learned a lot while there about things other surgeons have done to rip patients off. I met the patients. That is why I'm thankful for Dr Ortiz and his group. $250/nt for a nurse at the hotel seems unnecessary. I stayed in the hotel 2 nights after 2 nights in the hospital. I definitely did not need a nurse. I changed my own bandages that were provided by A Lighter Me. They gave me bandages, tape, pain meds with directions written in them (non narcotic, Toradol) which I didn't need because I had no pain, antibiotics with directions and a bottle of mylanta to take prior to abx. They were in a goodie bag of items for hospital stay. My driver also took me to a pharmacy where I purchased a supply of Omeprezole that I need to take for a few months. I bought 4 months worth for $60. Much cheaper than Prilosec OTC in Walmart. The lack of follow through my friend experienced would only be related to the split in that Dr Lopez left A Lighter Me, where they actually take care of their patients. He now contracts with a different group. Wow! I'm sorry your friend had such a horrible experience. I know that the docs still contract thru Mexico Bariatrics in addition to their own practice. Maybe I'm getting more attention because I'm dealing directly with the docs? I don't know. This is probably the first negative I've read about them. I'm glad to read that you recovered well after surgery. I'd like to think I have a high pain threshold (after 4 Cesarean sections), but it's still comforting to read stories like yours. I'm going to do some comparison shopping with A Lighter Me as well.

Thanks 1Day, The physicians are a bit ridiculous here. The choice to go to Mexico comes with a lot of "what ifs?" Part of the decision making process for me is determining the importance and relevance of each of my questions. If a complication arises, it just happens. I wouldn't necessarily have any more control over the situation in Florida vs. Mexico. I wasn't planning on having surgery until this summer while the kids are out-of-school. I have a consultation scheduled with the Florida doc in April. I think it would be prudent to keep the consult and get a feel for the doctor. I've had some really bad experiences with some docs that were too cocky to listen to their patients. That's part of my interest in a Mexico based physician. I feel like they will be more responsive to my concerns because they rely on these tourism dollars and are focused on building (and maintaining) a good reputation. Either way, I'm happy that I have time to make a decision that I'm comfortable with.

Thanks Nola, That is a good point. The doc I chose in Florida is considered the "grandfather" bariatric surgery here. He was the first in the state to perform the sleeve using the Spider technique. I think he's performed over 12,000 surgeries in addition to being a bypass patient himself. So he's definitely qualified, but that doesn't mean that he's the only one that can perform the surgery safely. Ally

Belladonna, One of my points was that the physician I selected in Florida is over two hours away. Therefore if a complication did arise, I would not be going back to him for follow-up. I would seek local care. So either way, I would be on my own for follow-up. Good point about the insurance coverage for complications. If I use insurance for the procedure, I won't be responsible for paying for any additional charges once my MOOP is met..... Provided it occurs during the same calendar year. I need to research the medical tourism insurance policies for comparison. Ally

Hi MmHutch, I'm really surprised that your friend didn't receive any support. Do you know if she went through a coordinator or Drs. Lopez and Osuna's practice, Specialized Bariatrics? Maybe the lack of follow through is one of the reasons why they created their own practice? I haven't even paid the deposit or decided on a date, but I've already received tons of information from their office including pre and post-op instructions. Regarding Dr. Ortiz, didn't he train under Dr. Lopez? I thought I read in one of the posts that he was Dr. Lopez's assistant before venturing out on his own. I have the option of requesting a private nurse once I return to the hotel for $250 per night. I haven't decided yet whether or not I want to do this. I've been a nurse for over ten years so I've seen how the healthcare system here fails people. I spent over seven years in Managed Care so I have first hand knowledge of the insurance industry too. From what I've learned, the care will probably be better in Mexico because the providers and facilities are catering to tourist dollars... That's a lot different than most of the facilities we deal with here unfortunately.

Thanks for asking this question. I'm also a remote worker and I was contemplating how to schedule the surgery. My company doesn't provide PTO in the normal sense. We have unlimited PTO (with Project Manager and immediate manager) approval. But still, I didn't want to burn thru time if it wasn't necessary. I'm thinking that I should be mentally ready after a couple of days. My only concern was still being tired as a result of pain or nausea. Ally

Hi Curvy, I posted about my fee a couple of weeks ago. I'm in Florida and the surgeon is charging $600... Personally I agree that it is an immediate way to secure non-refundable cash. This "Program Fee," covers 30 days of Vitamins, concierge services (like I can't book my own hotel room), access to a multidisciplinary team (but in actuality doesn't include mandatory nutritional counseling, or the psych eval, just the post-op Nut visit), support group (I live three hours away and think paying for an online support group is ridiculous) and educational material (guess they've forgotten about the internet). I'm disgusted at this point because the offerings in Florida are slim if I go thru insurance (UHC) due to the requirements of the Bariatric Resource Program purchased by my employer. I'm seriously considering Mexico at this point. Ally

Hi Missy, The doc selection may vary based upon her payment source -- self pay vs. insurance. If she has insurance then she may be restricted to only doctors that practice at centers deemed by the insurance company to be a center of excellence. Or she may have no restrictions at all. I have UHC and my employer opted for their Bariatric Resource Program. So I have restrictions regarding which docs/facilities I can select. I'm in Tampa, but I considered going to ORMC's Bariatric Center that is headed by Dr. Jawad because I don't like Tampa General. People on various boards really seem to like him. There is also a good program at Ocala Regional headed by Dr. Ramos. I contacted both practices and opted not to use either of them. Dr. Ramos' practice (Central FL Surgical Svcs) wanted me to get a referral from my PCP. Why? She has nothing to do with my surgery and it isn't an insurance requirement. It's not that I don't like her.... I don't like paying $75 for an office visit that I don't need just to get a referral. Then you really have to watch out for Jawad.... I made an appointment at their office and was told the first visit would consist of a group session, a consult with the physician and a discussion with the insurance coordinator to review my benefit coverage. No issues so far. They sent me a link for the paperwork and on the last page was an acknowledgement that the group session would be billed to my insurance and if it was not covered by my insurance, I would be responsible for the $200/250 fee. This was a new one for me. Basically the info sessions provided at ORMC are free. But if you book an appointment directly with the office, they charge the $200 fee for the session to be conducted there. If insurance isn't an issue then she might want to start researching hospitals and use their doc find search function for a list of either Bariatric Surgeons or General Surgeons that practice Bariatrics. Some people prefer certain hospitals over others. I opted for US Bariatrics in St. Augustine -- Flagler Hospital. Hope this helps. Ally

No worries. I figured it was a glitch. ; )

Thanks Linda! I'm more worried about nausea and pain. I will have to remember to make the car "extra comfy" and get an order dissolvable Zofran.

Now you've given me something to think about. It didn't occur to me that I might need to stay in the area for a follow-up. It's not a problem, St. Augustine is beautiful and I have enough points with Marriott and Hyatt to cover my hotel stay. Did you have Marema or one of his partners?

Hi Linda, I'm in Florida too. Where did you or will you go for your sleeve? Ally

W8loser, Does your insurance company have a Bariatric Program -- are you assigned to a Bariatric Nurse? If so, I agree with the other poster that you should contact notify your nurse. If you are not a part of a Bariatric Program, then I'm not sure that contacting your insurance company would be worthwhile at this point. But you might have a couple of options. Definitely try to establish with another PCP quickly.... but this is easier said than done right? Take a look at your insurance company's medical policy regarding the GS. Most will allow solid documentation from Weight Watchers or Jenny Craig in addition to clinician (MD/DO, ARPN, RD) documentation. For example, United Healthcare will accept Weight Watchers or Jenny Craig documentation in conjunction with documentation of at least two physician visits. So you could use Weight Watchers as an alternative this month if you are unable to see your physician. Hope everything works out for you.

Sorry Sarahjane I misunderstood.The term post-op was throwing me off. A year's worth of follow-up visits and nutritional support is a great price. I'm jealous! I would totally buy into a program like that. But these folks down here.... I'm telling you, they're just cray cray.

After investigating a couple of different surgeons I'm starting to think that "Program Fees" are commonplace. On average, the fee is approximately $600 and non-refundable. That's a lot of money when you consider how many people they see in their office -- this includes those that are seen and for whatever reason opt not to proceed with the surgery. That money is gone. When I read what the Program Fees support, I'm not really impressed. Thirty day supply of Bariatric Vitamins, access to the multidisciplinary team, educational program (nutrition and exercise), support groups and concierge services. Okay I can buy vitamins on my own for much, much less. I'm already paying out-of-pocket for Nutritional Counseling services ($225 for six visits). Access to the multidisciplinary team? Uhm really? At this point in my life I know how to book a hotel room and can probably get a better rate than them. I'm not going to their support groups because they are three hours away and will probably never visit the office again after my follow-up. Either way I'm moving forward with this process but I really feel like the docs are taking advantage and padding their bottom line. As it is I have a $3000 deductible and MOOP of $6000. Anyone else going through this? Tone: Calm, but annoyed.