Insurance or Self Pay in Mexico

[AK_Bookworm 116]

I live in Alaska and there are only two surgeons in the entire state... if I'm correct one only does gastric bypass and the other does the different procedures but neither provider is considered in network so instead of 90% insurance coverage I will only have my surgery covered at 80%... my insurance only covers the first $30,000 at the 90% for in network and then 80% after the first $30,000 but my surgery would cost me 20% plus my deductible and the maximum out of pocket doesn't apply to bariatric surgery... I also know WLS is pricey in Alaska but I don't know exactly how much... I'm at a crossroads because I love the idea of having my surgeon local especially because I'm leaning towards SADI-S over VSG but I'm concerned going the insurance route will cost me more than just going to Mexico. Any advice or recommendations? I don't want to go through all of the testing only to find out I can't afford surgery locally even with insurance.

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[highfunctioningfatman 2,675]

Call the place where you are interested in and give them your insurance information. The will be able to run your insurance, verify coverage and tell you exactly what your out of pocket costs will be. Make sure that they quote you for all required classes and follow up appointments and not for just the procedure.

Fyi, I went to Mexico.

[AK_Bookworm 116]

That's a good idea... I'll start there and then I'll be able to decide which option will be cheaper.

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[teedsg 250]

@@AK_Bookworm, and also see if they cover your supplies, I.e. shakes, Vitamins, meds etc

[RickM 1,747]

A few random thoughts in no particular order -

Does your insurance cover the SADI - many consider it to be experimental/investigational and don't cover it, while others do,

Many insurance policies provide, one way or another, for covering out of network doctors as in network when there is no in network coverage for a specific treatment in your area. It may just be extra paperwork to get an exemption or filing an appeal for an initial decision.

Depending upon when during the year your surgery occurs and what other insured expenses that you have had during the year, you may run into the max out of pocket threshold of the policy, where they start paying 100%. My surgeon is out of network but was paid 100% because by the time Aetna stopped dragging their feet and paid him we had hit that threshold.

There are a number of good surgeons who take advantage of the lower cost structure of working in Mexico to offer a good product at an attractive price. Within that cohort you may find some that advertise a sleeve for $4000 while others charge 6000 or more - do you want to go with the cut rate surgeon or the more experienced one with a good reputation. Consider that when comparing costs with your at home co-pays.

If you are interested in the SADI, I would certainly bias myself toward staying at home. This is a newer procedure where the long term effects have not been fully characterized. Long term follow ups with your surgeon would be a good idea as they may find certain deficiencies crop up over time within their patient population so they may change their lab protocols, adding or deleting tests as experience dictates. My wife is 11+ years out on her traditional DS (I'm 5+ out on a VSG,) and still gets annual lab follow ups from the surgeon - it helps them in understanding how things evolve as their patients age as well as helps us keep things in balance with the altered anatomy. That's a valuable benefit of keeping things local if you choose a more complex or less well known procedure.

[AK_Bookworm 116]

@@rickm very good points. I have Aetna as well so it appears I have some other things to look into. I am sure my insurance does cover SADI however I could be reading it wrong but I do know it covers DS so if I have to do DS I'm ok with that. If I was doing VSG I wouldn't worry about follow up as much but because I'm not that is something that's important. I am hoping to have surgery between August and September so I think it's far enough in the year to meet my maximum out of pocket and deductible. I think I need to do whatever possible to stay home. I did call Aetna and ask if they would cover as in network since we don't have an in network provider here and the guy I spoke to just didn't seem to care to answer my questions and simply said no and suggested going out of state to an in network provider and seeking for them to reimburse me for travel cost but that also would be an outside provider and I would have my surgeon local. I think my decisions is made now it's time to start the process.

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