Hi there - I don't know quite how to word this, but I feel like my surgeon's office is stringing me along and like perhaps I won't get approved and they know it?

My BMI is on the lower side at 36 - but I have diabetes, high BP, high cholesterol, and PCOS (poly cystic ovarian syndrome). My Dr and I discussed it and she is fully on board with me having WLS. All those other co-morbidities are actually being caused by my PCOS, and she gets it because she has it too, and had WLS herself. She wrote down the name and number of the surgeon's office I should call - so I did and set myself up as a new patient. They are well respected - and I personally know 4 other people who have had WLS through them with no complaints.

I went for my initial consult back in June - they ran my insurance (UHC Empire Plan - my husband works for the State of NY and apparently we have great insurance, it even covered all of our IVF 100%. I mention this not to "brag" but in case it's helpful - I am not from the US myself and the whole health insurance process really confuses me. We have universal health care in the UK where I'm from).

So anyway - at the consult my insurance was run, I was weighed, talked to the surgeon. I was told that they handled all the "other stuff" in terms of requirements for insurance. Was told I needed to come back every 30 days to be weighed and that I should come back in July. That was a snag - I told them I go home to the UK for the summer, and wouldn't be back until the end of August - they said that it was fine and just come in again "at some point" after I get back.

I went and weighed in on Aug 21st - they asked for my insurance card again and one office person said to another that there was a "flag" on my account. I was weighed and nothing was mentioned about any problems. I didn't ask because I am clueless and also a big wuss.

I went and weighed in on Sept 21st. I asked about additional appts - psych eval, nutritionist, etc. and was told that it would all get done nearer to the time when they apply to the insurance.

Wasn't the insurance application already made? Why am I feeling like I'll get to the end of the 6 months and be told that I'm not eligible? Is it because it's just not what I'm used to? Is there stuff that I should be doing on my end that they're assuming I'm doing? I had looked up our insurance and it said about covering surgery with a BMI of 35 as long as there was a comorbidity (and I have several). My surgeon comes up as covered under our insurance - but the hospital he practises at doesn't? Even though it's the same hospital I had my breast reduction surgery in and it was covered. I don't know.

I just feel like I'm traipsing along to these weigh ins and am not really part of things. I'll be halfway through my 6 months in a couple of weeks, but I still feel like absolutely everthing is up in the air and wishy-washy. I suppose the real answer is that I need to grow a pair and ask some questions, but it feels good to voice my concerns.

Many insurances require you to be in a Circle of Excellence for Bariatric Surgery Hospital. Not all hospitals qualify for that...it's very specific.

Also, typically, you are not allowed to miss any appointments or you start over from the first day.

Also you should qualify with ins based co-morbidities of diabetes and possibly on high BP if you are on 3 meds for it and it's still high. Otherwise, 36BMI is at the cusp of not getting in. If you have to wait 6 months to do your pre-op visits with the RD, monthly, and you go below 35BMI, you are screwed and will be denied.

That's just from a lay perspective, I am not an insurance specialist. It's a very grueling and stressful process and filled with "Will I's or Won't I's". Keep plugging.

For me, my surgeon runs the insurance initially to ensure it is covered. Then you go through all the hoops (the nutritionist, psych eval, weight loss, whatever)... and THEN they actually seek approval for the insurance. The first check with insurance is to make sure you have the right coverage and to get the guidelines from the insurance company to see everything they need to approve it. My insurance covers the surgery over a certain BMI... but they still have other requirements you don't see that they don't outright tell you unless you ask, that the surgeon gets (i.e. nutritionist clearance, psych clearance, etc).

I was scared that I would go through all of the appointments and then at the end insurance would deny it, but that didn't happen. It doesn't sound like your doc is stringing you along. You have to complete all of the requirements from their office and from insurance before insurance will approve it. Insurance does not approve it in the beginning, but at the end.

Edited October 10, 20187 yr by mousecat88

They don't submit to the insurance for approval until you've jumped through all the "hoops" required - in my case, my insurance required 6 consecutive monthly visits with a provider in the surgeon's office, a sleep study, a visit with a clinical nutritionist, psychiatrist, and cardiologist, and a couple of other things. It sounds like you may just not be used to the insurance system in the US. Your chart was probably flagged because you came for your initial appointment but failed to come back for consecutive appointments, so you're essentially starting over.

Like others have said, you have to do the appointments before they submit for approval. I have a 12 month waiting period where I have a monthly call in appointment with a nurse from my "active health" department at my insurance, psych eval (which the surgeon said to do at least six months in to my year wait), nutritionist at least once and one support group meeting.

It is a lot of steps but if you ask the surgery group they are usually happy to explain requirements specific to your insurance since they know it better.

16 hours ago, Boldilocks said:

Hi there - I don't know quite how to word this, but I feel like my surgeon's office is stringing me along and like perhaps I won't get approved and they know it?

My BMI is on the lower side at 36 - but I have diabetes, high BP, high cholesterol, and PCOS (poly cystic ovarian syndrome). My Dr and I discussed it and she is fully on board with me having WLS. All those other co-morbidities are actually being caused by my PCOS, and she gets it because she has it too, and had WLS herself. She wrote down the name and number of the surgeon's office I should call - so I did and set myself up as a new patient. They are well respected - and I personally know 4 other people who have had WLS through them with no complaints.

I went for my initial consult back in June - they ran my insurance (UHC Empire Plan - my husband works for the State of NY and apparently we have great insurance, it even covered all of our IVF 100%. I mention this not to "brag" but in case it's helpful - I am not from the US myself and the whole health insurance process really confuses me. We have universal health care in the UK where I'm from).

So anyway - at the consult my insurance was run, I was weighed, talked to the surgeon. I was told that they handled all the "other stuff" in terms of requirements for insurance. Was told I needed to come back every 30 days to be weighed and that I should come back in July. That was a snag - I told them I go home to the UK for the summer, and wouldn't be back until the end of August - they said that it was fine and just come in again "at some point" after I get back.

I went and weighed in on Aug 21st - they asked for my insurance card again and one office person said to another that there was a "flag" on my account. I was weighed and nothing was mentioned about any problems. I didn't ask because I am clueless and also a big wuss.

I went and weighed in on Sept 21st. I asked about additional appts - psych eval, nutritionist, etc. and was told that it would all get done nearer to the time when they apply to the insurance.

Wasn't the insurance application already made? Why am I feeling like I'll get to the end of the 6 months and be told that I'm not eligible? Is it because it's just not what I'm used to? Is there stuff that I should be doing on my end that they're assuming I'm doing? I had looked up our insurance and it said about covering surgery with a BMI of 35 as long as there was a comorbidity (and I have several). My surgeon comes up as covered under our insurance - but the hospital he practises at doesn't? Even though it's the same hospital I had my breast reduction surgery in and it was covered. I don't know.

I just feel like I'm traipsing along to these weigh ins and am not really part of things. I'll be halfway through my 6 months in a couple of weeks, but I still feel like absolutely everthing is up in the air and wishy-washy. I suppose the real answer is that I need to grow a pair and ask some questions, but it feels good to voice my concerns.

So I used to have this health plan too as I worked for the State as well, congrats it is great.

No the application to the insurance company comes at the bitter end and it's usually what we are all nervously waiting for.

You go through all the other appts to gather "proof" and submit as "evidence" then they make a ruling on your "case"

I would ask what that flag was all about. It could be as simple as needing to get a new card, to there being a change in policy. You'll want to know ahead of time.

If you are in a rush, tell them you have a time frame you want to have to the surgery in. You may have come off as not having a pressing deadline/urgent need because of the vacation.

You can also absolutely contact the insurance company itself and find out the requirements that need to be met to qualify for coverage (ask for it in writing)

Safe Journey!

Edited October 11, 20187 yr by GreenTealael

Thank you all so much for your replies it seems a bit clearer to me now.

20 hours ago, FluffyChix said:

Also, typically, you are not allowed to miss any appointments or you start over from the first day.

Also you should qualify with ins based co-morbidities of diabetes and possibly on high BP if you are on 3 meds for it and it's still high. Otherwise, 36BMI is at the cusp of not getting in. If you have to wait 6 months to do your pre-op visits with the RD, monthly, and you go below 35BMI, you are screwed and will be denied.

FluffyChix - I know that I have to kep my appts consecutive - I hope I didn't come off like I was trying to sneak my trip home under the radar. They explained to me at my June consult that I would start my 6 months of weigh-ins when I came back to the US in August. Going home every summer is necessary to my mental health, so I was willing to take the 2 month hit. What's 2 months in the grand scheme of things anyway?

Also - I have the criteria from United Healthcare and I am fine at 35 BMI as long as I have 1 co-morbidity. However, now I am worried about falling below 35 during this 6 months, and no longer being eligible. I will be mindful at that and ask that at my next weigh-in - thank you!

20 hours ago, mousecat88 said:

For me, my surgeon runs the insurance initially to ensure it is covered. Then you go through all the hoops (the nutritionist, psych eval, weight loss, whatever)... and THEN they actually seek approval for the insurance. The first check with insurance is to make sure you have the right coverage and to get the guidelines from the insurance company to see everything they need to approve it. My insurance covers the surgery over a certain BMI... but they still have other requirements you don't see that they don't outright tell you unless you ask, that the surgeon gets (i.e. nutritionist clearance, psych clearance, etc).

I was scared that I would go through all of the appointments and then at the end insurance would deny it, but that didn't happen. It doesn't sound like your doc is stringing you along. You have to complete all of the requirements from their office and from insurance before insurance will approve it. Insurance does not approve it in the beginning, but at the end.

Mousecat88 - this makes a lot of sense to me the way you explain it. Kind of like running your credit card when you check into the hotel, but not charging it until you leave, LOL. So I think I'm on the right track, and I just have to "trust the process." I'm not a control freak - but I just hate it when I don't understand why something is or isn't happening. When I'm comfortable in the facts, then I'm fine.

20 hours ago, mousecat88 said:

20 hours ago, MegPRN said:

Your chart was probably flagged because you came for your initial appointment but failed to come back for consecutive appointments, so you're essentially starting over.

MegPRN - I didn't even think of that at all, but you may very well be right! Especially as the "flag" was mentioned at my first visit back to the surgeon after a 2 month absence, but wasn't mentioned the next visit. Thank you!

18 hours ago, Bootscraper said:

Like others have said, you have to do the appointments before they submit for approval. I have a 12 month waiting period where I have a monthly call in appointment with a nurse from my "active health" department at my insurance, psych eval (which the surgeon said to do at least six months in to my year wait), nutritionist at least once and one support group meeting.

It is a lot of steps but if you ask the surgery group they are usually happy to explain requirements specific to your insurance since they know it better.

I am definitely going to ask about the timeline for my other steps at my next weigh in!

5 hours ago, GreenTealael said:

If you are in a rush, tell them you have a time frame you want to have to the surgery in. You may have come off as not having a pressing deadline/urgent need because of the vacation.

You can also absolutely contact the insurance company itself and find out the requirements that need to be met to qualify for coverage (ask for it in writing)

I'm not in a rush - I knew that the 6 month countdown would start in August not in June, as this was explained to me before I went away on vacation. Now that I am thinking about it, during my consult the insurance people at the surgeon's office did talk to UHC to see if they would allow me to do weigh-ins at a doctor's office in the UK, but the answer was no. So I knew I was starting weigh ins in August and having my last one next January.

Thank you all again - this has been really helpful!

6 minutes ago, Boldilocks said:

Thank you all so much for your replies it seems a bit clearer to me now.
I'm not in a rush - I knew that the 6 month countdown would start in August not in June, as this was explained to me before I went away on vacation. Now that I am thinking about it, during my consult the insurance people at the surgeon's office did talk to UHC to see if they would allow me to do weigh-ins at a doctor's office in the UK, but the answer was no. So I knew I was starting weigh ins in August and having my last one next January.

Thank you all again - this has been really helpful!

Also - I reread the literature from my consult, and it says that the other steps will start 2-3 months out from surgery date. Doh.

Edited October 11, 20187 yr by Boldilocks

I had to postpone one of my monthly weigh ins for a week(got tied up at work and couldn't make it and the next available appt was the following week)...will that cause me to have to start over?

The wait has been grueling. My nutritionist was stranded in NY for one of my appointments and we conducted it by phone. But, then, she also forgot to tell me that if I gain as much as 1 pound during the nutrition phase, my insurance might turn me down. I passed, though with my deteriorating knee joints, I’d been gaining an average of 5 pounds per month. I think every doctors office does it a little differently. Mine only requires a 2 day pre-op diet, while most require 2 weeks. Good luck on your journey.

Call the insurance company if you feel weird asking the surgeons office. They can answer any questions for you.

On 10/18/2018 at 12:36 PM, NYJenn said:

Call the insurance company if you feel weird asking the surgeons office. They can answer any questions for you.

I have a terrible phone phobia, so I def feel less weird about asking questions at the surgeon's office! ?

I wanted to check in with an update because so many people were good enough to chime in and offer reassurance.

I had my 3rd weight check of 6 yesterday, and it was a nurse I hadn't seen before who was chattier than the others and offered some info without me needing to ask.

She took my weight and it was up 0.4 of a lb from last time, but still down overall about 2 lbs. She said that she shouldn't really be saying it, but not to lose any weight for the next 3 weigh-ins because I am so close to the limit. I am at 36 BMI, and my insurance allows a BMI of 35 with an added comorbidity (not an issue, I have 3). She told me that with my insurance, it is not the initial weight that is taken as the qualifying number - if my weight falls below 35 BMI at any subsequent appointment, it will disqualify me.

She also said that between the 3rd and 4th weight checks is when they start scheduling other appts and the surgery date itself, so that they should be calling me with that in the next couple of weeks.

Incidentally, with my insurance, apparently they are real sticklers for the weight check being every 30 days. Day 30 would be this Sunday for me, and I called ahead and said I wouldn't be able to come in Monday, so would Friday be OK. They said it was - and when I was there I asked if my next weight check should be 30 days from that day, or 30 days from the day it was supposed to be. She said 30 days from yesterday - and that it's better to be a day under than a day over if the day lands on a weekend or holiday, or you can't otherwise get to the office for weigh in on day 30.

Boldilocks - what health insurance do you have? I'm wondering if BCBS of GA will be like yours. Good luck with your journey! Your posts have been great . I'm so nervous but also really curios. Thanks!

Don't you just hate those pain-unmentionable-area people? It may be Their Money but it is Your Body! Didn't anyone teach them to play nice?

1 hour ago, MegHealthy said:

Boldilocks - what health insurance do you have? I'm wondering if BCBS of GA will be like yours. Good luck with your journey! Your posts have been great . I'm so nervous but also really curios. Thanks!

I have United Health Care, but it is through my husband's job as a NY State employee. It's also called the Empire Plan, and I believe BCBS for hospital coverage. If you have read above, you know that I find this insurance malarkey very, very confusing! ?