I posted this in another thread, but I have yet to receive any replys so I am starting a new topic.

kind of a dumb question. I have oxford insurance. Its a cheap policy that I have been paying out of pocket for. I did the whole 6months of seeing a primary care doctor. I got an endoscapy, chest x-ray with breathing test, letter from a shrink, letters from the surgeon and my primary care doc, and a bunch of other things. So I got approval and I am slated for surgery on wed.

I was looking through a packet that oxford sent me about a month ago. Just a standard packet showing policy benefits and limitations. On one page there was a list of excluded proceedures and bariatrics was on that list. Now I know they cover the surgery because about a year ago when I was checking out different doctors one of the nurses called my insurance co with my policy number and type and was told the surgery is covered. So I just find it strange that in that list bariatrics would be something NOT covered.

So should I be worried? I mean I have approval and whatnot. They cannot just refuse to pay the surgeon after they approve someone right?

also I was looking at the benefits section and I will have to pay a small co-pay for the 2 day hospital stay which is fine. I am worried about them paying for the surgery in full and the anesthesia. Now I know the anesthesiologist takes my insurance and since im approved for the operation.....

I would love for someone to chime in here. Do you think the insurance company has to pay everything in full since they approved me or could they screw me over and say we approved you for the surgery but we are not paying...... I do not want to call the insurance co and screw anything up.. I am only 6 days away from being post op.

idk maybe I am just over reacting.

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When I get a copy of our insurance policy from work, almost always there are riders attached. They start with a standard policy and revise from there. If you received approval, I would'nt worry too much about it. Do you have the approval in writing? If not, you could have the insurance company send you a copy for your records. You could call them and ask the rep what exactly your out of pocket expenses will be. Oftentimes it is a percentage.

Good luck!

I've never had an insurance company not pay once they have approved. However, depending on your policy you may have to pay co-insurance. Mine is 3000.00

When i checked in i was asked to sign a form that gave my consent for the hospital to sue the ins. Co to collect the agreed amount they didn't pay as promised. Also. If you have a deductible that you haven't met yet (mine was 127.00) you will pay that.

You should receive a letter of approval from the insurance company too

When I get a copy of our insurance policy from work, almost always there are riders attached. They start with a standard policy and revise from there. If you received approval, I would'nt worry too much about it. Do you have the approval in writing? If not, you could have the insurance company send you a copy for your records. You could call them and ask the rep what exactly your out of pocket expenses will be. Oftentimes it is a percentage.

Good luck!

Thanks for your reply. I was just speaking to a nurse freind of mine who has since put my mind at ease. I guess this pre op diet is making me a bit on edge and thinking the worst. I think you are right that it is just a standard list that they attach to all packets they send out. It did scare me though. I do have a letter of approval, but at the bottom it says payment is based on "member enrollment and eligibility", "terms, conditions and limitations of the members health benefits plan".

I guess those are just standard lines as well. I thought if your insurance approves you then they have to pay. I mean I understand that I have to pay whatever co-pays, but I was under the impression that they have to pay the surgeon in full.

I have never heard of percentages. any idea what percentage is normal?

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I've never had an insurance company not pay once they have approved. However, depending on your policy you may have to pay co-insurance. Mine is 3000.00

When i checked in i was asked to sign a form that gave my consent for the hospital to sue the ins. Co to collect the agreed amount they didn't pay as promised. Also. If you have a deductible that you haven't met yet (mine was 127.00) you will pay that.

You should receive a letter of approval from the insurance company too

Thanks for your reply. I do know I have to pay 500 for hospital stay co-pay or whatever. I dont mind having to pay little things. I was just worried about the insurance co not covering the bulk of the costs. I do have the approval letter in hand.

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I called my insurance 7 months prior to surgery just after I went to the WL seminar and was told bariatric surgery was covered under my contract. My surgeons office also received written approval prior to scheduling my surgery date. After surgery I found they covered the hospital, anesthesiologist and pathologist but denying the surgeon bill. They also covered 6 months of dr appts, psych eval and other required steps. I have filed an appeal.

Thanks for your reply. I was just speaking to a nurse freind of mine who has since put my mind at ease. I guess this pre op diet is making me a bit on edge and thinking the worst. I think you are right that it is just a standard list that they attach to all packets they send out. It did scare me though. I do have a letter of approval, but at the bottom it says payment is based on "member enrollment and eligibility", "terms, conditions and limitations of the members health benefits plan".

I guess those are just standard lines as well. I thought if your insurance approves you then they have to pay. I mean I understand that I have to pay whatever co-pays, but I was under the impression that they have to pay the surgeon in full.

I have never heard of percentages. any idea what percentage is normal?

I imagine the amount varies. For my insurance I had my deductible, then the insurance paid 80%. I was responsible for the next 20% but only until I reached my maximum out of pocket expences. It isn't a perfect indication, just what mine was. My total out of pocket was about $4000.

I called my insurance 7 months prior to surgery just after I went to the WL seminar and was told bariatric surgery was covered under my contract. My surgeons office also received written approval prior to scheduling my surgery date. After surgery I found they covered the hospital, anesthesiologist and pathologist but denying the surgeon bill. They also covered 6 months of dr appts, psych eval and other required steps. I have filed an appeal.

how is that possible? what happens if you lose your appeal. how much is the surgeons bill. I dont understand how they can approve all those other things but not pay the surgeon.

My thoughts exactly! There would have been no need for anesthesia and a hospital stay if I hadn't had the surgery. My Drs office has not had this happen before either. The surgeon bill was 7000.00 and I already paid my 1000.00 out of pocket to the hospital. Crossing fingers til I hear back.

My thoughts exactly! There would have been no need for anesthesia and a hospital stay if I hadn't had the surgery. My Drs office has not had this happen before either. The surgeon bill was 7000.00 and I already paid my 1000.00 out of pocket to the hospital. Crossing fingers til I hear back.

wow that is a real crummy situation. I hope they work it out. I am glad to know though that it is a freak occurance. I am having my surgery in nyc and I know the expense will be high whatever it turns out to be. I just hope something like that does not happen to me.

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What I found interesting is that the total bill for self pay in my area is about 13000. I have friends who paid it. So. I went with the same dr and hospital and was expecting to pay about 1300 for my 10%. Negative! They said insurance companies are are charged 35000...if thr y didn't charfe them that they would never make any money. Really? Thatbis why insurance is messed up!!!! So my part will be 3500 if my insurance agrees to pay the asking price...which I doubt. Its so messed up!

What I found interesting is that the total bill for self pay in my area is about 13000. I have friends who paid it. So. I went with the same dr and hospital and was expecting to pay about 1300 for my 10%. Negative! They said insurance companies are are charged 35000...if thr y didn't charfe them that they would never make any money. Really? Thatbis why insurance is messed up!!!! So my part will be 3500 if my insurance agrees to pay the asking price...which I doubt. Its so messed up!

Where are you from? I'm cash pay in Oklahoma and my cost is 16500!! Ouch!!

Cash pay in Dallas with Dr Nicholson is 12200.00 at its pretty much inclusiv of everything.

Baton rouge, Louisiana

What I found interesting is that the total bill for self pay in my area is about 13000. I have friends who paid it. So. I went with the same dr and hospital and was expecting to pay about 1300 for my 10%. Negative! They said insurance companies are are charged 35000...if thr y didn't charfe them that they would never make any money. Really? Thatbis why insurance is messed up!!!! So my part will be 3500 if my insurance agrees to pay the asking price...which I doubt. Its so messed up!

The amount billed by hospitals, drs, etc.. is usually higher than ins companies pay anyway for any services even regular appointments with a PCP. I don't get billed for that difference. The provider or facility absorbs it. Just the insurance biz I guess. So self pay patients usually get a lower rate than insurance bills.

I called my insurance 7 months prior to surgery just after I went to the WL seminar and was told bariatric surgery was covered under my contract. My surgeons office also received written approval prior to scheduling my surgery date. After surgery I found they covered the hospital, anesthesiologist and pathologist but denying the surgeon bill. They also covered 6 months of dr appts, psych eval and other required steps. I have filed an appeal.

Update- I received in the mail a denial for my 1st appeal. Denied as uncovered. Just the surgeon's bill, not the hospital, anesthesiologists or pathologist. So today I was doing to fill out the forms for my 2nd appeal which would involve my employer. I checked Priority Health's website which I've done frequently since surgery and the claim appeared to have been paid??? hmmm I didn't want to get too excited. I had a 1pm 3 month f/u apt and confirmed with the office that PH had indeed paid the claim. They still haven't told me. Glad I didn't send in the 2nd appeal without checking:) Sure made my day!!!!!!