RavenClaw779

There was a forum question re; doctors "scamming" patients which got me thinking. I have a commercial insurance background and stay on top of my medical insurance claims as I've had a number of denials over the years which were actually mistakes on the part of the carrier's claims adjustor. Sadly, turnover in insurance companies is high. Burnout especially in the claims area is understandable due to the stress. Often the people hired have minimal experience in the field and no medical background. It really is in your best interest to know your policy and ask questions. I don't think the United States needs universal health care, but we sure do need reform and oversight. Here are some great example from my own claims generating from the pre-surgical process: *Basic Bloodwork $832(Billed to BCBS); $104 (BCBS - Allowed) - Required although I'd just had bi-annual labs with my primary two months prior. *Medifast Nurse (15mins) $82.22(Billed to BCBS); $22.93 (BCBS - Allowed) - Didn't even include the Medifast product *Pulmonologist (30 mins) $263 (Billed to BCBS); $134(BCBS - Allowed) - Wow; he asked the same questions already asked by another dept at the same facility and available online. Listened to my heart and lungs and told me that despite no flags for sleep apnea I had to go to sleep lab and have another "pre-surgical" appt with him. This is why I love the Mayo Clinic. Their doctors are salaried and while their services are not cheap, they test because it's necessary not to gin up charges.

I went for the initial last Thurs. I fail to see how this creates an accurate profile of ones sleep habits. I get to bring my own pillows, but I'm in a strange bed, in a room that's way too hot(I live in the Adirondacks and shut the heat off at bed time...so my room is about 55 degrees at night), with wires stuck to my head and face with some greasy waxy paste. I can't get up and go to the bathroom with out asking(wired to the wall) and the light must be out - so I can't read in bed before going to sleep plus I'm in bed FOUR hours before my normal bedtime. Needless to stay I bearly slept and got home the next afternoon feeling like I'd been hit by a truck! As far as the diet - I've been on about 500 calories for the past month. There are times(esp in a cold climate) that I've layered a heated throw and several blankets on the couch and burrowed in. My cat loves snuggle time!

Started this process with the info seminar on November 14...first meeting with surgeon on 2/1. Paperwork submitted to BCBS of MA on 2/22 - approval faxed to surgeon 2/25! Surgery 3/9/10:thumbup:

Was hoping to avoid that second trip to the sleep lab tonight - using my unplowed 90' driveway of snow as an excuse...sadly, must go or the surgeon will cancel the surgery. Guess the hubs better get home early and get to work shoveling:laugh: Was so hungry yesterday I ate a couple of whole grain waffles and a bagel. Was prepared for the worst when I stepped on the scale. DOWN - to within a pound and a half of my pre-surgery goal weight. My nutritionist said that when you're on an extremely low calorie fasting diet, your metabolism slows down to accommedate less fuel coming in. By eating a little more I "tricked" my body into feeling like everything's status quo. Added one packet of nutrasweet to the Jillian Michaels shake - cuts that horrid stevia bittersweet aftertaste. Managed to choke it down...

Was hoping to avoid that second trip to the sleep lab tonight - using my unplowed 90' driveway of snow as an excuse...sadly, must go or the surgeon will cancel the surgery. Guess the hubs better get home early and get to work shoveling:laugh: Was so hungry yesterday I ate a couple of whole grain waffles and a bagel. Was prepared for the worst when I stepped on the scale. DOWN - to within a pound and a half of my pre-surgery goal weight. My nutritionist said that when you're on an extremely low calorie fasting diet, your metabolism slows down to accommedate less fuel coming in. By eating a little more I "tricked" my body into feeling like everything's status quo. Added one packet of nutrasweet to the Jillian Michaels shake - cuts that horrid stevia bittersweet aftertaste. Managed to choke it down...

(Must be boring everyone to death - no one has any comments...) Two weeks from surgery. I found I was allergic to the MediFast shakes with the soy so I changed to the MediFast "cold drinks" (per the nurse - "no soy"). I'm to have five shakes a day plus add'l protein as needed. I've now had "the runs" for two days and just the thought of eating anything makes me feel sick. Still 3 pounds from pre-surgery goal weight.

(Must be boring everyone to death - no one has any comments...) Two weeks from surgery. I found I was allergic to the MediFast shakes with the soy so I changed to the MediFast "cold drinks" (per the nurse - "no soy"). I'm to have five shakes a day plus add'l protein as needed. I've now had "the runs" for two days and just the thought of eating anything makes me feel sick. Still 3 pounds from pre-surgery goal weight.

I'm pre-band...3/9/10 is my "due" - when I give birth to the new me(and stop having people ask me when I'm due:lol:). One thing I've heard over and over, online and from friends and support group members was "I just wish I'd done it sooner". That speaks volumes to me; I wish I'd faced the reality that though I've got it together as far as my overall life is concerned, my weight is something that I have not been able to control on my own. My weight has kept my from doing many things I've wanted to do and I've wasted half of my 30's and half of my 40's in a fat suit. No more! I love to cook and bake and my family loves my "good eats" - of course they're none the wiser that many of my recipes are from Weight Watchers or have been altered using healthy alternatives.

Here's a laugh...a gal from my baratric support group and a family friend both saw the same PsyD as I did and we all came to the conclusion that this woman was nuts or just doing it for the money. In my case she asked me over the phone for my insurance info so she could confirm my coverage. At the consult she told me since I hadn't met my deductible I'd have to pay her out of pocket then and there. When I told her this wasn't the way my plan worked she had a mini-meltdown and I ponied up rather than to reschedule what turned out to be pointless. She wasn't able to finish the survey and had to call me one night the following week to finish up!?! Then she emailed me my invoice and told me she'd also file it with my insurance company. When she didn't, I sent her a reminder note and she told me that since she'd sent me the invoice it was my job to handle reimbursement!?!? I called my insurance company to find out how to do this and they told me it was her job and that she'd overcharged me - i.e., not the negotiated rate for my carrier. They're planning to review her contract and advise her that she's in the wrong!:rolleyes2:

Here's a laugh...a gal from my baratric support group and a family friend both saw the same PsyD as I did and we all came to the conclusion that this woman was nuts or just doing it for the money. In my case she asked me over the phone for my insurance info so she could confirm my coverage. At the consult she told me since I hadn't met my deductible I'd have to pay her out of pocket then and there. When I told her this wasn't the way my plan worked she had a mini-meltdown and I ponied up rather than to reschedule what turned out to be pointless. She wasn't able to finish the survey and had to call me one night the following week to finish up!?! Then she emailed me my invoice and told me she'd also file it with my insurance company. When she didn't, I sent her a reminder note and she told me that since she'd sent me the invoice it was my job to handle reimbursement!?!? I called my insurance company to find out how to do this and they told me it was her job and that she'd overcharged me - i.e., not the negotiated rate for my carrier. They're planning to review her contract and advise her that she's in the wrong!:tongue_smilie:

Besty B and I have the same childhood background re; controlling, diet obsessed mama! My mother is 5'6" and 118; ditto for her mother...however her brother(my uncle) is obese as is my brother so weight issues can be both environment(emotional) and hereditary. I started really battling my weight in my early 30's and have been severely obese for 10 years. For me the band is the last step in a growth process not limited to nutritional counseling and admitting I have a problem I can't control on my own. That said, my on-going nutritional counseling, learning about portion control and healthy eating/cooking is going to allow me to truly control my weight and my health. It won't and can't be the job of the band alone. Start with meeting with a registered dietation. Maybe have an indirect calorimeter(test that tells you how many calories you need on a daily basis), learn portion sizes, food journaling BEFORE you take a drastic step like surgery.

It really depends on your insurance carrier - in fact I have heard of incidences where a patient has begun the WLS process under one insurance carrier's parameters, met the qualifications, deductible, what have you then their employer change carriers and they're back to square one OR find that they are able to proceed much faster than with the prior carrier. Even within carriers the plans very. I'm with BCBS or MA through my husband's employer. It's a PPO. The BCBS of another state or even a BCBS HMO can be totally different. *It's always a good idea to either have a hard copy or PDF on your desktop of your current plan - not just the highlights, but the fine print and exclusions. *You can call the customer service at your plan and get a different answer every time - and it may not be the right answer. You need to be able to reference your plan specifics and be prepare to file an appeal if necessary...and not just for this procedure. Carefully review your EOB's(Explanation of Benefits) - I can't tell you how many times I've had to question a denial or incorrect payment only to get the "Whoops - My Bad" type of response. Saves me a ton of money. Here's a cut and paste of my plan's baratric coverage as an example: Charges for surgical services for morbid obesity, including gastroplasty and gastric bypass surgery only if: 1. prior authorization is received from the claims administrator; and 2. presence of severe obesity that has persisted for at least five (5) years, defined as either: a) body mass index (BMI) exceeding 40; or :tongue_smilie: BMI greater than 35 in conjunction with any of the following co-morbidities: i. coronary heart disease; or ii. type 2 diabetes mellitus; or iii. clinically significant obstructive sleep apnea; or iv. medically refractory hypertension (blood pressure > 140 mmHg systolic and/or 90 mmHg diastolic despite optimal medical management); and 3. patient has completed growth (18 years of age or documentation of completion of bone growth); and 4. patient has attempted weight loss in the past without successful long-term weight reductions; and 5. patient has participated in a consistent program that is physician-supervised with integrated components of a dietary regimen, appropriate exercise and behavioral modification and support; and 6. an evaluation has been performed by a multi-disciplinary team with medical, surgical, psychiatric and nutritional expertise, and 7. for patients who have a history of severe psychiatric disturbance (schizophrenia, borderline personality disorder, suicidal ideation, severe depression) or who are currently under the care of a psychologist/psychiatrist or who are on psychotropic medications, a pre-operative psychological evaluation and clearance is necessary in order to exclude patients who are unable to provide informed consent or who are unable to comply with the pre- and postoperative regimen. Note: The presence of depression due to obesity is not normally considered a contraindication to obesity surgery.

Congrats to everybody! Mine's been moved up to 3/9 but the patient coordinator still hasn't submitted it to BCBS of MA for approval. Sure hope I don't end up with an insurance nightmare.:tongue_smilie:

What a surprise - despite no hallmarks for sleep apnea I was forced to go to the sleep lab and attempt to sleep in a hot room with two loud fans and wires all over my head and face plus two tight elastic bands across my chest. Now I have to go back to be fitted for a CPAP(cha-ching$$$). I keep hearing this scenario from other patients - that it's almost pre-decided you have sleep apnea...:rolleyes2:

What a surprise - despite no hallmarks for sleep apnea I was forced to go to the sleep lab and attempt to sleep in a hot room with two loud fans and wires all over my head and face plus two tight elastic bands across my chest. Now I have to go back to be fitted for a CPAP(cha-ching$$$). I keep hearing this scenario from other patients - that it's almost pre-decided you have sleep apnea...:tongue_smilie:

Update: Family dinner last night at the s-i-l's. Family friend who is four months post-op came and we all dished. Family was able to see that she is able to eat normal foods just not as much. Everyone including my husband seemed relieved to see the reality(she's gone from a size 26/28 to size 14/16) and hear the details of what the immediate post-op will be like - livable. LOL though - I brought my MediFast "Raspberry Tea" for dinner and it was still impossible to get my s-i-l to grasp that No - I can't just have some XYZ with my shake(all shakes until surgery date) and my m-i-l brings out a pie which she sits between me and the family friend and starts cutting and handing out pieces. The FF had to explain that the piece was too big for her and I had to (once again) decline the "can't you just have a little piece with your shake". I guess at 88 she's stuck in her ways - another family friend was at the dinner; he's 3 weeks past a heart attack and two stents and of course watching his diet - she tried to stick him with a piece of pic the size of Long Island! FF and I are still trying to get the s-i-l past her declarations of "I could never do this because I love to eat..." FF told her -she loves to eat too, and can, but now just a taste will do instead of 2 or 3 platefulls. Slow learners...:frown:

I'm within three pounds of my goal weight for surgery and not really hungry. But I am so tired I can hardly muster the energy to do the laundry. As a rather fanatical housekeeper, this ain't good. Big snow storm coming and my husband is going out of town on business. Since he's refused to buy a snowblower(he prefers to shovel our 90' driveway by hand?!!) he's suggested I just get an early start tomorrow shoveling. Had to so say no to that one - like I could shovel this monster on under 500 calories??:rolleyes2:

I'm within three pounds of my goal weight for surgery and not really hungry. But I am so tired I can hardly muster the energy to do the laundry. As a rather fanatical housekeeper, this ain't good. Big snow storm coming and my husband is going out of town on business. Since he's refused to buy a snowblower(he prefers to shovel our 90' driveway by hand?!!) he's suggested I just get an early start tomorrow shoveling. Had to so say no to that one - like I could shovel this monster on under 500 calories??:tongue_smilie:

No word so I called for the results - everything is okay despite my weight and prior history of chemo...

No word so I called for the results - everything is okay despite my weight and prior history of chemo...

Thanks everybody - Finally talked to my s-i-l today...after I got yet another voice message about another family dinner out at a restaurant(Methinks the reason we have some weight issues in the family maybe all the eating out!)... She wanted to know all about the process and told me how everyone in the family was afraid to invite me to dinner(because I can't eat) and afraid not to (because my feelings might be hurt). Sigh. I explained that at least for the near future, going out to eat or other food centered events is a no go for me(too too tempting after weeks of MediCrap) but that I'd love to go shopping or to the movies. So family friend whose had the procedure and my s-i-l and I are getting together tomorrow to dish over coffee(black, no creamer...):thumbup:

I have my own nutritionist who I've been working with for a while, but I was required to meet with a nutritionist affliated with the hospital. Guess I expected more from the meeting. I wasn't weighed or asked how the Medifast was going. The nutritionist was a recent grad with little personality. The only way I caught her name was by her ID tag. She acted bored and as if she was dealing with an idiot. Let me guess - if you're fat, you're probably a dunce. She had all her required checklists all lined up in a rack and was whipping them out like a well-oiled machine. We went through the same questions I answered before my first visit with the surgeon, and during my psych consult. She read the Post-Surgical diet to me and told me to call if I had any problems. Meanwhile her phone line rang and rang. Methinks I'll be calling my own nutritionist.:redface:

I have my own nutritionist who I've been working with for a while, but I was required to meet with a nutritionist affliated with the hospital. Guess I expected more from the meeting. I wasn't weighed or asked how the Medifast was going. The nutritionist was a recent grad with little personality. The only way I caught her name was by her ID tag. She acted bored and as if she was dealing with an idiot. Let me guess - if you're fat, you're probably a dunce. She had all her required checklists all lined up in a rack and was whipping them out like a well-oiled machine. We went through the same questions I answered before my first visit with the surgeon, and during my psych consult. She read the Post-Surgical diet to me and told me to call if I had any problems. Meanwhile her phone line rang and rang. Methinks I'll be calling my own nutritionist.

Checked in at 7pm and immediately had to get into my PJ's. Thought it odd until the whole wiring process began - took almost an hour. Nice room - set up like a hotel with a half bath, but way too warm for me. And since I usually go to bed between 11:30 and 1:00am, 10:30pm was tough. Barely slept - too warm, two fans going was unbelievably loud - sort of felt like a hot summer night when the A/C has died and you dooze at most. I'm punchy now and ready for bed - it's only 7pm!

Checked in at 7pm and immediately had to get into my PJ's. Thought it odd until the whole wiring process began - took almost an hour. Nice room - set up like a hotel with a half bath, but way too warm for me. And since I usually go to bed between 11:30 and 1:00am, 10:30pm was tough. Barely slept - too warm, two fans going was unbelievably loud - sort of felt like a hot summer night when the A/C has died and you dooze at most. I'm punchy now and ready for bed - it's only 7pm!