:welldoneclap: hi, newbie in tn, just at the begining process go to first appt. in oct 3 2006. I have medicare/medcaid just curious how the process is? and how long? any info would be great. thanks!!!

This is from the Medicare National Coverage Policy for Bariatric Surgery

Nationally Covered Indications

Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index >35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. These procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006).

A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site at http://www.cms.hhs.gov/center/coverage.asp, and published in the Federal Register.

Hope this helps

jeannine

thanks jeannine , for the info . I do fit the requirements. I am in for the long haul with all of this paper work. but it is definetly worth it.

hi..

I have virginia medicaid and lets see... they told me I had to get a referral from my PCP so I went to do that.. and I had to do 3 months weight documentation to go with the other 3 months I'd already done.. finally got a preop date which is Dec. 14 and I'm waiting for my stack of paperwork the hospital is suppose to be sending me in the mail. So all in all, I guess it wasn't long... just the weight documentation took sooooo long.

My understanding is that Medicare does not need pre-approval. If the procedure is covered, than the physician does not require pre-approval.

I am a Medicare lapband patient (or will be) but unfortunately because it is Medicare the waiting list is longer and I probably can't have surgery until February. At least that is what I was told by staff.

My question is has anyone on Medicare run into a situation where if you can come up with the difference between what Medicare pays and what the doctor wants for his services, that it's possible to work with the doctor's office on this and get your surgery date moved up?

Is it a certain quota of Medicare patients that the doctor is required to work with?

Thanks,

Gail:help:

I haved tried to find out if south carolina medicaid covers the band...i have medicaid b/c i got pregnant, which i found out 4 days before my lapband was supposed to be placed in nov of last year at that point i was a self pay, can anyone help point me in the right direction for finding out this information

thankx

Brooke

hi guys, well I went to my first dr appt. found out with medicare is pretty easy IF you meet the requirements. I do meet the over 35> bmi and aleast one comordities. which I have high blood presure. they require. just extra paperwork :medical records back from 3-5 yrs,referral from primary dr. stating health issues reguarding weight, pysch exam with extra testing a personlity test with 370 questions. accept to be there for aleast 3 hrs. which I am bipolar with disablity from bipolar. so the lap band psych dr. is requiring me get a statement from my regular bipolar psych dr . stating that he thinks I am mentality okay with the going through with the surgery . which my regular dr is the one who told me about the surgery. so he already told me that if I needed a referral, it would be no problem. So now I have an appt. on oct. 20 with the dietitan . once I get that done.the Lap band dr office told me that I would be finish with my

paperwork then I could get started with the procedure with all the normal test they run before the operation.dr office said hopefully if every thing goes well I could be looking at having the surgery by the end of the year. oh yeah also they are requiring for me to pay a 500.00 program fee up from before surgery . now I am kinda getting jitters about the actual surgery.but I will be okay!!

well I will keep everyone post through the process. talk to ya later. bye.:clap2:

I am a Medicare lapband patient (or will be) but unfortunately because it is Medicare the waiting list is longer and I probably can't have surgery until February. At least that is what I was told by staff.

My question is has anyone on Medicare run into a situation where if you can come up with the difference between what Medicare pays and what the doctor wants for his services, that it's possible to work with the doctor's office on this and get your surgery date moved up?

Is it a certain quota of Medicare patients that the doctor is required to work with?

Thanks,

Gail:help:

Gail,

I think the problem is not a monetary one as far as reimbursement goes. When medicare changed the rules and said they would only pay for Surgery done at a Center of Excellence that is what caused the backlog of medicare patients. ALL medicare patients in the country can only have surgery at the 173 Centers of Excellence nationwide. If physicians didnt limit how many medicare patients they took per month they would have no room for the other patients that are either private pay or insurance. I know when Medicare changed the rule we had Medicare patients from all over the South calling us for appointments because there are only 10 COE's in Texas, 4 in Louisanna, 1 in Oklahoma and none in New Mexico or Arkansas. We had literally hundreds of patients trying to get surgery done. I'm not sure coming up with extra money would be the answer to getting you done sooner but it would be worth a shot if you have extra cash laying around.. but I am not sure it is legal for them to accept payment from you above and beyond what Medicare pays.

Kathy

Thank you Kathy.

I just emailed my surgeon's office a few days ago and was still waiting for an answer to some of these questions I had. I haven't heard back so your reply was very timely and informative for me. That would certainly explain the extended consultation and surgery date.

Western Bariatric of Reno is a COE. Lucky for me!

Kathy,

I am looking for a surgeon in the Dallas area who performs the surgery at a Center of Excellence, which is difficult to find. I have no idea why Medicare has made this decision, but I have discovered by researching surgeons online that the surgeons with the most experience and least number of complications do not practice at the approved facilities. For example, Dr. Kim uses North Hills Hospital, but he has only performed 150 lap-band surgeries. However, Dr. Hamn in Plano has done over 1,500, but he can not perform surgery on Medicare patients because he doesn't practice at an approved facility. That doesn't make sense to me at all. I want a doc who has done tons of surgeries to do mine for obvious reasons. I am an RN and tend to very picky about those types of things. I also wanted to add that I looked at the Medicare website and found 11 facilities in TX now.

I have Medicare and I didn't have to wait for my surgery. I had my surgery done less than 2 months after my initial consultation with the surgeon. I had it done by Dr. Szomstein at the Cleveland Clinic in Weston, Fl. I guess I was one of the lucky ones, now waiting to see if they pay. I don't see why they wouldn't, my BMI was well over 40. Good luck to you. The only thing I heard though is that Medicare only covers 1 fill after surgery, the rest you have to pay for yourself, which my dr. charges about $600!

Well yesterday I went to take my chest xray ,adomnal ultrasound and ekg. then today I went back to do my lab work which is all done at baptist east hospital. well everything was covered except the HIV test ,hepatistis test and Iron test .which they said medicare does not cover that at the hosptial under coverage the A plan. and told me i have to pay 750.00 before I can have my lab done . well I was very disappointed and upset .which I called my primary dr. they said I couldhave these test done in the dr. office so I go monday.I hope this all works out . and no more set backs .the dr office is consider medical b plan on medicare I dont know . I just hope I can get this done without paying it all up front or it is going to delay my surgery. then if I can get past this all I have to do is get my upper G.I. the sit back and wait for results. this stuff with a simple lab work is making me crazy. i just hope monday gets here soon.

Hi , I have a medicare advantage plan which they go by medicare guidelines.

The surgeon's office told me I must go to seminar and then pay $600 for something , you get a book, nutritionalist,whatever else. I said I cannot afford that, I am on disability. She said save it. How do you save that on a fixed income? I told my insurance co., she said I don't see why you would have to pay that. I cannot so that will be the thing to stop me from getting lapband. I will be very unhappy.

Did you ask Medicare about the $500? Thanks.

Karen