allycatt98

Yes my coordinator ended up giving me what I'll have to pay and I pay it at my pre-op appointment but I'm hoping by the end of my 6 month supervised diet I will have met my oop max in which I'm about $231.00 away from meeting. I'm so jealous!

Well being that I am the one that posted it my issue was that 2 months into the process financials still had not been discussed by my surgeon's office advising me what or when I needed to pay not the fact that I had to pay. My insurance company can't tell me what the surgeon or hospital fee is or when they require it only what my policy covers, my deductible, oop max etc. DonaiA,Your insurance company actually can provide you an estimate of charges just as they provide it to the physician. The estimate will be based on the contracted rate for the surgeon and/or procedure. It's just a matter of giving you the negotiated rate that will be in your EOB up-front. But what they can't tell you is how much the physician will require up-front. I can understand your frustration on this point. I won't be having surgery until July, but I contacted the hospital to get more info about payment expectations. When I told them the surgery hadn't been scheduled yet, they didn't want to talk to me. I've got a $3000 deductible and $6000 MOOP. I can't wait until a week before surgery to find out how much they want to collect up-front. Were you finally able to get the pricing info from the office?

Theard, I was a Pre-Auth Nurse so I will share what I know about the process. 1. Some offices try to flood you with paper (labs, office notes, imaging, etc.) -- it's annoying and it doesn't help the patient's chances for approval. I couldn't stand it. Seriously, 100 pages! How about giving me the info I need to make a decision? 2. Missing/Incomplete documentation: All the required documentation must be submitted. If five years of documented weight loss is required, then that's what the nurse is looking for. If there is a nutritional counseling requirement, then the nurse is looking for complete records from the practitioner that include diet, exercise, etc. You'd be amazed how many people miss this one. The NUT and Psych documentation must include all the elements required by the insurance company. Many of the commercial plans have templates available that you can give to your practitioner. 3. Medical Necessity isn't met: This one is a biggie and will often cause an immediate denial. Those letters of medical necessity that the docs send in are often a waste of time and are usually only useful at the time of an appeal. If criteria isn't met, then your Doc needs to be prepared to discuss the reasons why you need the surgery with the health plan's Medical Director. They can call in while the case is being reviewed or do a peer-to-peer review after it is denied. Basically, the doc has to care enough to prove your case. Some do, some don't. Hope this helps. Let me know if you have any questions. P.S. The 30 day timeframes a quoted are BS. Medicare: 14 calendar days for standard (non-emergent) requests with an additional 14 calendar days if an extension is granted because it is in the best interest of the enrollee; i.e. additional time to submit required documentation or have tests done to meet criteria. The health plan is required to advise you in writing if an extension is needed AND you have the right to file a grievance if you disagree. Medicaid: every state is different (i.e., New York and Missouri require a three business day TAT. But if additional info is needed the NY cases are allowed to go up to 14 calendar days). The default for all Medicaid states is typically 14 calendar days. Some states require an even shorter TAT as mentioned. Even if an extension is granted it is typically only for up to 14 calendar days. NCQA accredited health plans: If the TAT criteria listed above does not apply (i.e. Commercial Health Insurance) then check the plan's accreditation. NCQA requires a no more than 15 calendar day TAT with an additional 14/15 calendar days if an extension is granted. However, you still have to be notified in writing than the Health Plan granted an extension AND the notice should specify why it's being granted. I know I typed a lot. Hopefully it helps. Sorry for any typos, I'm on my iPad. Ally.

I have UHC with the Optum Bariatric Resources Program. So my physician/hospital choices are extremely limited. There are approximately ten hospitals in my area, but I can only use one of them per the plan and I'm not going to Tampa General. I can do better for a $3000 deductible. Other than that, my requirements aren't bad: 6 months of nutritional counseling and a psych eval. I go for my third visit on Thursday. So I'm projecting a July surgery date. Nutritional counseling of course isn't covered by the plan, so I opted to use the RD sessions offered at Florida Hospital's Wellness Center -- 6 sessions for $250. Next, I have to go see my Hema/Onc to develop a strategy for surgery bc of my bleeding disorder and then take care of the psych eval. I'm scheduled to go back to my surgeon for the pre-op right after my last NUT visit late June. I'm anticipating a three business day turn-around for the approval. Ally

Jess, Gallbladders are tricky. Many people experience Biliary Colic and don't attribute it to their Gallbladder. It often resembles indigestion. Some women like me find out about their gallstones during pregnancy as a result of the OB Ultrasounds. I was probably experiencing the symptoms for years without knowing what was the cause. Was this enough to make me have it removed? Nope, but add-in upcoming sleeve surgery (hopefully in July) and now I'm ready. Rapid/Frequent weight gain/loss can contribute to the formation of the stones. I take Zofran as needed for nausea and digestive enzymes for acid, fatty or spicy food. I was sooooo relieved when the surgeon said he would just remove it at the time of the sleeve without forcing me to pay for additional imaging (ultrasounds, HIDA Scans, etc.). I have a $3000 deductible and don't want to incur the costs. Does your surgeon require an abdominal ultrasound prior to surgery? If so, then he/she can make an informed decision about your Gallbladder. Not everyone needs a Cholecystectomy after the sleeve. But those that lose the weight really quickly may be at a higher risk. Hope this helps. Ally

Hmmm that's interesting. I think a lot of that may have been in response to insurance requirements. I had one dr tell me I needed a referral and letter of medical necessity from my PCP. I pushed back because it wasn't necessary. I just checked a different Drs website and he performs the esophageal motility testing, but notes additional clearances may be needed based upon your insurance. No other standard clearances are required.

Like what? The Psych eval is standard, I have to get that one too. What other types of clearances are people getting?

ChiChi search the forums for Squatty Potty. I'm so glad I came across a post about it. While I am pre-op, it has still been such a great help. You can also find more reviews on amazon.com. Ally

Are these clearances the norm for everyone? Or is it just based upon your health history? So far the only "clearance" I've been told to obtain is from my Hema/Onc prior to surgery.... Really it's more of a formality since I was going to her for an Iron infusion prior to surgery anyway. No ultrasound needed (my wallet is grateful) because I have a recent history of gallstones and the dr is going to remove my gallbladder at the time of surgery. Other than Wellbutrin I don't take any meds or have any comorbidities.... I'm wondering if that's why he hasn't mentioned other testing? Ally

I'm a former OB nurse and I had a Mirena inserted in the early 2000s without a problem. I loved it. Then when I had it replaced after my son was born I had one issue after another. It worked better for me when I was in my twenties than in my thirties. I had recurrent UTIs and other side effects. It just wasn't worth it anymore. My situation might be different. I did not and do not use oral bcps.... So my body wasn't used to the changes anymore. I got tired of the changes and just opted to use condoms. If we were to have a slip-up, I would just buy Plan B over-the-counter. Best wishes to you!

I'm in the Tampa Bay Area and I'm hoping to be sleeved by Dr. Koppman in July.

Anyone that is a smoker has an obligation to report it to their surgeon. Smoking increases your risks of a leak in addition to other post-op complications. Your doc can't prepare or plan for this if you aren't honest. There is a possibility that your surgery will be cancelled, but isn't that better than all of the what ifs that could happen? If something were to happen, you may lose any recourse against the physician because you weren't honest. Either way, I'm wishing you the best for your surgery and new life. ; ) Ally

I'm so happy for you and jealous at the same time. Please once you're able, post your experience with Dr. Lopez. July can't come fast enough for me.

Additional surgery may not be warranted regardless of the location of your surgery. There isn't a crystal ball to say that you will need your gallbladder removed in the future and I doubt insurance will pay for removal without there being evidence that its necessary. There are plenty of people who make the decision to go to Mexico when they have insurance coverage for reasons as varied as financial, the wait being too long, they feel they will receive better care, more surgical experience, etc. I'm glad you have come to a decision you are comfortable with and I hope you have a smooth surgery and recovery. Thanks for the reply. I really don't think you understand any of this, but that's okay.

Thanks to everyone that replied to my post and was willing to provide their perspective and recovery information. I feel a lot more comfortable about my decision to move forward with the surgery and I'm encouraged by all of the success that you all are having. It feels like I've been driving all day. I drove three hours away for a consult and then turned around and came back home....Whew! I like the doctor and I've heard great things about the facility. Based upon my past history of gallstones (they were actually noted during an OB Ultrasound two years ago) he recommended removal of my gallbladder at the time of the sleeve surgery. The rapid weight loss experienced with the sleeve would only aggravate my poor gallbladder even more post-surgery. There will be additional charges for the Cholecystectomy but I dount my responsibility would be much considering that I would've already met my MOOP after the sleeve. So it looks like I will be remaining stateside.... at least for the sleeve. Once I reach my IBW (Ideal Body Weight) I'm definitely jetting off to MX for a total body lift. Ally

Uhm okay. I didn't have any questions about insurance coverage... I'm good in that respect. My post was to get different perspectives from people regarding the insurance vs. MX issue. All things being equal (quality of care, etc.), would you consider having surgery in MX as a cost saving measure. Consideration would have to be given for any extra fees charged by the MX surgeons for hernia repair or a Cholecystectomy as this reduces the potential cost savings. It really doesn't make sense to have the surgery in MX but then come back to the states for additional surgery.... It would be an all or nothing deal. There's no need to pay for surgery in MX then come back to the states and pay the MOOP I was trying to avoid for additional surgical procedures.

I disagree.... A hospital discharge is not indicative that the person no longer requires medical services or follow-up. It simply means that they no longer require the level of care required for an inpatient stay. This is one of the reasons that home health care has evolved into its current model. So yes, some people may require the services of a nurse (i.e. home health) after hospital discharge. It happens everyday and from a financial perspective, it is much more cost effective than an additional day in the hospital -- especially one that is not quoted/covered in the package price. So considering the availability of home health services as a factor when picking a coordinator is sound. For the most part, a majority of people can be discharged safely after a 1-2 day inpatient stay and I'm extremely encouraged by this. The point of my post wasn't to debate the merits or efficacy of surgery in Mexico. It was to get a different perspective regarding insurance vs. MX. If I didn't have insurance and MX was the only route for the surgery then I would "chin up" as you mentioned and opt for the trip. However, I have insurance so my decision making process is a bit different. I'm concerned now that if I do require additional services (i.e. hernia repair, gallbladder removal, etc.) the cost of the trip to MX will end up equaling if not exceeding my original insurance projections of $6000. I'm glad you had a great experience and I hope the same for everyone else. But this surgery (regardless of the location) should be thoughtfully considered. I want to make sure that I've performed my due diligence.

Hi CiCi, I'm going up to St Augustine tomorrow for my consult. I'm dreading the trip (almost three hours each way), but I look at it as a necessary evil. I need to find a surgeon and be done with this. I'm really hoping that the doc and I hit it off tomorrow. I totally respect skill and expertise, but at the end of the day, I need someone that is capable and willing to listen to my concerns and act on them. Sometimes that's hard to find. I'm wishing you the best with your MX preparations. I'll let you know what happens tomorrow. Who knows, I could totally end up in MX this July. Ally

Hi Sassy, I'm in the Tampa Bay Area hoping to get sleeved in July by Dr. Koppman at Flagler in St Augustine. There are only a handful of hospitals that United will allow me to use.

Ha the process is purposely bewildering. : ) I would try to go on the insurance website and research information on your own. Knowledge is always power and it helps you hold onto your money. Best wishes to ya! Ally

Referrals and physician orders are completely different. I was referencing the orders you would need for the testing... Why rack up additional charges right now if you don't need to. Use the money to pay for any pre-op testing.

I bought one last month. It's awesome! But I will admit to giggling when I read the reviews on Amazon.

Your BMI is what it is. Besides you can't do any testing without an order anyway. Let your surgeon determine the best course of action. I'm assuming that you've been at your current weight (or more) for over a year right? If so, a pound or two lighter isn't going to make a difference. Your previous medical records should be able to document a BMI of 40 or more so don't sweat it. People fluctuate all the time.... Your weight during your initial consult is what will be considered....Unless this is a recent spike. But if you've consistently been at 40 or above you should be good. Ally

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