Confused By The Insurance

[Boldilocks 313]

I am so confused about all the insurance stuff - and I know that this isn't the best place to get specific help, but I'm hoping that it can just be made clearer for me.

I'm not American - I'm from the UK and we have universal healthcare, so the insurance thing has always confused the feck out of me!

I live in upstate NY, my husband works for the State and therefore has very good insurance. It covered our IVF and my breast reduction surgery 100%, for example. It's United Healthcare - but is also apparently the NYS Empire Plan. But it is Blue Cross Blue Shield if there is a hospital stay involved??

Anyway - I went to my primary care doctor. She has the same problems as me (PCOS - an endocrine issue, one of the main symptoms of which is weight gain with the inability to lose, and ultra low metabolism). She has had weight loss surgery herself, and so was quick to recommend it. She gave me the name of a surgeon, but didn't give me referral letter. I signed up as a new patient on his website, completed the mandatory seminar, and set up an initial consult.

I went for the consult last Thursday (06/07/18) and they weighed me and took a history. The nurse said my insurance requires 6 months of weigh ins, which have to be done every 28-30 days. This threw a spanner in the works, because I go home to the UK for the summer, leaving early July. Because I am not back until the middle of August, I was told that I would have to start in September - I wanted to come in August, but was told that it had to be in September because it goes in 4 weekly blocks. Maybe she meant from the date of the consult?

So they said I would have to see the nutritionist, have an endoscopy, a psych eval, an EKG, a colonoscopy. I pretty much expected that as I had looked up our insurance plan's rules for surgery: https://www.empireblue.com/medicalpolicies/policies/mp_pw_a053317.htm

I am right at 36 BMI and the policy for BMI with co-morbidity (I have PCOS, diabetes, high cholesterol) is 35. I was not told to lose weight - but what will happen if I fall under 35 while doing the weigh ins?

Also, they said that after the 6 weigh ins and other procedures, they forward it to the insurance. Does that mean that it could still be denied? Am I essentially doing this blind right now? I read about people hear calling their insurance - am I supposed to be doing that? Do I need to get prior authorisation for this, or is the weight loss centre supposed to deal with it? Again, I'm sorry if Im being really dumb - I just want to understand the process.

[ColletteCAJ 1]

Hi! I too was told by the insurance coordinator that I needed to do 6mos of a supervised diet and psych evaluation. I was super bummed because I had met my insurance deductible already for this year and that time would put me at the new year for the insurance. After searching and searching on here I found a few posts where the insurance coordinator was wrong. So, I decided to call my insurance to further investigate how i could get around this and was told by them, ( i have United Healthcare ChoicePlus) that i do not have to do anything but have the bmi or bmi with 2 comorbiditys.

My insurance coordinator was actually argumentative with me and said I would be the first in blah, blah years..... After insisting she submit it anyways, I was approved in a week first letter.

So, Definitely call your insurance- I called 3xs to make sure it was the same answer every time!

[ColletteCAJ 1]

Also, Technically it could still be denied but they will make sure you have done everything your insurance requires so it does not. They will submit all the requirements with the prior authorization-

[newmebithebypass 713]

First since you have united health care they have a bariatric nurse that you will need to work with call the member services number on the back of your card and ask to speak to a benefit counselor they can tell you everything in your specific plan also by law it is all required to be online so you can create a login thru your specific company and see it all in clear print right online