Nurse Navigator NOT Helpful Thus Far

[SummerTimeGirl 580]

So I'm new here and started a thread last week with some questions I had. You can easily find it if you want but pretty much I was asking WHY the bariatric office would contact the insurance company BEFORE they even allow me to go for an initial consult. I mean, the initial consult would better help me understand IF I even wanted to go through with the surgery to begin with and here they were almost acting as if they won't see me at all unless I have insurance that will cover it. Was just strange to me.

So then yesterday they write me back. They simply say this (they also sent a separate email with details on classes, links to videos to watch and told me to look in the mail for a binder):

Deductible: $150
Met to Date:

Out of Pocket: $2750
Met to Date:

Copay:

Coinsurance: 100%

Medically Supervised Weight Loss Classes: 0

That really doesn't explain anything. I mean, it tells me how much any coinsurance would cover (which I don't have) but not what my primary and only insurance will cover. So I messaged back to ask:

What DOES MY insurance actually cover?
When does the out of pocket expenses come into play, and can payments be made towards it instead of one lump sum?
Does the "Medically supervised classes: 0" mean I attended none or I don't need to attend one?
Are any of the additional tests needed for the surgery covered by insurance?

So they respond today and still don't really answer all of my questions. One of the things she said was:

"For the amount covered by your insurance you will need to call them for clarification."

Huh, I was told last week that's what THEY were doing. SMH

Then the last sentence she says:

"Once you have the surgery we will submit to your insurance company and they will let us know what part of the balance is your responsibility. At that point you would receive a bill. I hope this helps!"

ONCE I HAVE the surgery? WTH? Shouldn't they/I know what the insurance will cover BEFOREHAND? Gotta say, I'm not really happy right now. This is exactly why I wanted to go for a consult in person to ask all these questions. I mean, is this normal? Out of everything I've read here I can't say that I remember anyone saying they got the surgery and THEN were told what the damages were after the fact. This is all very discouraging but they are supposedly 1st tier in my network which means it SHOULD be covered 100% as I do believe my insurance covers this surgery 100% (a co-worker had it done with the same insurance a year ago). I mean, what is the job of these people if I am to call and find all this out myself? I was told in the first email they sent me that THEY would be contacting my insurance to see what all it covers then they would get back to me with the answers and the next steps to take. SMH I mean, am I over reacting or is this confusing and crazy to any of you too?

[njlimmer 338]

I get the frustration, but I think this is pretty normal - or at least mine was very similar. They verified that my insurance covered it before I went in for my appointment, but after my consultation, they suggested that I call my insurance for clarification and that really helped. Your insurance company will have to explain the out of pocket stuff to you, but basically the numbers change and they can't give you a hard and fast figure NOW because things change.

For example, I had my EGD (endoscope) on Jan. 8th and I had to pay almost $850. My deductible is $800. When the doctor's office called me with my surgical info, they told me a number that'd I'd have to pay on a certain date. When I mentioned what I had paid for my EGD, their number changed because it takes FOREVER for insurance to get stuff in and processed and they didn't have the payment that I'd already made for the EGD.

So, if they quote you a number today... and life happens... it could be a different number by the time you're actually ready for the procedure. Also, they don't want to quote you XYZ and have things change to ABC and that cause more problems down the line.

I feel your frustration and it is confusing, but I don't think it's completely abnormal.

[SummerTimeGirl 580]

I totally get not giving me an exact number, but I would at least like to know if the insurance covers the surgery at all before I begin. And what, if anything else. Problem is I simply cannot go into this blindly not knowing what sort of financial responsibilities I may have along the way or even in the end. I mean, the numbers will be a HUGE deciding factor for me, sadly, because it has to be. As much as I MAY NEED IT, if I can't afford it I simply cannot go through with it. Thanks so much for your input.

[njlimmer 338]

31 minutes ago, SummerTimeGirl said:

I totally get not giving me an exact number, but I would at least like to know if the insurance covers the surgery at all before I begin. And what, if anything else. Problem is I simply cannot go into this blindly not knowing what sort of financial responsibilities I may have along the way or even in the end. I mean, the numbers will be a HUGE deciding factor for me, sadly, because it has to be. As much as I MAY NEED IT, if I can't afford it I simply cannot go through with it. Thanks so much for your input.

I absolutely get it. If my insurance didn't cover it, I wouldn't be getting it either, but based on what they DID tell you, it looks like as long as everything is in network, your max out of pocket is 2750. The way my insurance explained it was that you pay the deductible first. Then everything after the deductible is 80/20 with them paying 80% and me paying 20% so if the bill was 100, I'd pay 20 and they'd pay 80. That works all the way up until the 2750. Once you've paid 2750, then insurance should cover it 100% unless it's out of network - so if the bill is 100,000 - you should only have to pay 2750. Since the medical folks don't want to tell you too much, you're best bet is to call your insurance and tell them you want to get the surgery, ask what's covered and what's not, and are there any expectations in terms of classes, etc... That will give you more info in terms of the $$$ than the doc's office will.

[GreenTealael 24,857]

2 hours ago, SummerTimeGirl said:

. I mean, is this normal?

Yes Unfortunately.

I wish that there was just a set price for a procedure but it *seems* that when dealing with insurance companies (vs self pay) there is a range or a maximum Doctors and Hospitals will bill insurance companies.

If you were to pay for surgery completely out of pocket they *probably* could give you a better estimate mostly because your are billed upfront and sometimes after if there was an unexpected variable.

If you have access to any of your health insurance bills & documents (especially the Explanation of Benefits - EOB) check your last few appointments or procedures to see what was billed to your insurance, what the insurance actually paid and the patient responsibility amount (what you had to pay). That might help you understand your particular coverage a little better.

Also definitely call your insurance company to verify coverage of the procedure and ask for it in writing.

I know there are many people on this forum in the healthcare or Insurance field that may have even better explanations.

I hope that helps a little ❤️

Edited February 9, 2021 by GreenTealael

[SummerTimeGirl 580]

Thanks everyone for the great info. The part that is/was confusing to me is the fact that I guess I was under the impression that THEY would be gathering all that insurance info for me then explaining/breaking it all down for me. At least that's what they told me in the first email and also what it says on their website (says the "nurse navigator" is in charge of obtaining the insurance coverage info for you then breaking down what is covered and what isn't and how to proceed). But instead they told me SOME info then pretty much told me to get the rest myself. LOL THAT is the part I was wonder about being normal or not.

I think at this point I will just wait for the binder to come and see if maybe that contains any additional info. Then I will call my insurance company to get final answers on it all. She did say the monthly required classes were covered. So at least I know that. LOL

[Uomograsso 364]

If your all the providers are in your insurance companies network then all you should have to pay is deductible + out of pocket maximum, $150 + $2750 for a total of $2900. Everything after that should be covered at 100% after you meet your oop maximum. You should call your insurance company and confirm that or you could speak with your HR department at work if you have insurance through them.

[SummerTimeGirl 580]

15 hours ago, Uomograsso said:

If your all the providers are in your insurance companies network then all you should have to pay is deductible + out of pocket maximum, $150 + $2750 for a total of $2900. Everything after that should be covered at 100% after you meet your oop maximum. You should call your insurance company and confirm that or you could speak with your HR department at work if you have insurance through them.

Yeah, that's how I was reading it too but yesterday when the bariatric office called to set me up with my first meeting with the surgeon, I again asked about insurance coverage and what tests and whatnot was covered. The nurse told me that depended on the insurance and that I should call them to verify right after getting off the phone with her. So I did. Even though I reminded her that her office told me they were going to do that a week ago before anything could get started.

Anyway, no one was in the insurance office, or they were busy with others, so I left a message and they emailed me back right away. But they were not helpful either. LOL The insurance rep said yes, it's covered but requires prior authorization? Um, aren't THEY the ones to authorize? She then says, that my provider (where I will have my surgery done) would be able to tell me what is needed and required before surgery. SMH So they tell me to ask the doc office and the doc office tells me to ask the insurance company. I'm pretty much ready to give up. I mean, if I can't get straight answers now I can't imagine getting into this thing and having to deal with uncertainties then. SMH

[blackcatsandbaddecisions 844]

The entire process of WLS is filled with frustrations and setbacks- I’m sorry to say this is not likely to be the last situation that’s going to go like this. I’d recommend emailing the coordinator at the surgeons and telling her that insurance company indicated that they have information related to prior authorization requirements and you’d like to know what those are. They can’t submit for prior authorization until after all the requirements are met. I can tell you with my knowledge of insurance I’d plan on your cost being the out of pocket max plus deductible. I rarely see surgery any less than that.

On the subject of being ready to give up because of the insurance/office back and forth, I’d really recommend considering if this is the right time of your life to move forward with this surgery. You’re going to need a lot of patience and perseverance to be successful with this whole process, from insurance requirements to getting ready for surgery, to surgery, recovery, weight loss phase, and maintenance. Make sure you’re in the right mindset because in the end it’s your own determination and attitude that will be needed for this to be a successful process.

[SummerTimeGirl 580]

28 minutes ago, blackcatsandbaddecisions said:

The entire process of WLS is filled with frustrations and setbacks- I’m sorry to say this is not likely to be the last situation that’s going to go like this. I’d recommend emailing the coordinator at the surgeons and telling her that insurance company indicated that they have information related to prior authorization requirements and you’d like to know what those are. They can’t submit for prior authorization until after all the requirements are met. I can tell you with my knowledge of insurance I’d plan on your cost being the out of pocket max plus deductible. I rarely see surgery any less than that.

On the subject of being ready to give up because of the insurance/office back and forth, I’d really recommend considering if this is the right time of your life to move forward with this surgery. You’re going to need a lot of patience and perseverance to be successful with this whole process, from insurance requirements to getting ready for surgery, to surgery, recovery, weight loss phase, and maintenance. Make sure you’re in the right mindset because in the end it’s your own determination and attitude that will be needed for this to be a successful process.

Thank you. Yes, I was just blowing off steam. Just made me mad that I've been researching for years and finally decide to take the next step with calling to gather additional info, only to be blown off. Or at least it seems that way. I mean, you'd think they'd each know how to do their job and yet it doesn't appear that they do.

I just don't understand how the doc office says YOU need to call your insurance company and get prior authorization and figure out what is/isn't covered. Then when I do the insurance company says to call the doc office and find out the same thing. LOL I felt like I was in the twilight zone.

Anyway, I'm still waiting on the initial binder to get to me. I have my first surgeon consult on the 25th and the nurse said I need to have several classes over and done with BEFORE that happens. I also need to finish taking several tests based on those classes. Not much time left for all of that plus I'm still waiting to hear back from someone, anyone, about the insurance situation. So yeah, frustrated for sure. I don't mind doing the work but it would be nice if the ones running the show did theirs too. Ya know?

[blackcatsandbaddecisions 844]

I hear that for sure. The most important thing is that you now know the plan covers it which is great. Typically you’ll find a 3/4/6 month waiting period with md or dietician check ins every month, a psych eval and a nutritionist meeting. Mine required a PCP letter of recommendation too. It seems like a ton but it’s all over before you know it and suddenly you’re post op being like...oh right now I actually need to lose the weight.

I know my surgeons office became a lot more helpful once I had my initial consult- I think they get a lot of people who are interested and flake out, so once they saw I had coverage, I met the qualifications and I was going to jump through the hoops, they were more vested in helping. I read somewhere that less than 30% of people who meet with a surgeon and start the prequalification process end up finishing and getting surgery. Some have insurance changes, life changes, cold feet, etc. The whole thing is a process for sure, but it’s worth it!

[SummerTimeGirl 580]

28 minutes ago, blackcatsandbaddecisions said:

I think they get a lot of people who are interested and flake out, so once they saw I had coverage, I met the qualifications and I was going to jump through the hoops, they were more vested in helping.

Yes, this is what I'm hoping. That once I get that initial consult they will finally get things moving in the right direction because they'll see I'm serious.

[blackcatsandbaddecisions 844]

And honestly if they don’t get better then you still have time to switch surgeons. I went to a surgeons office a few hours away from home so I could see the MD of my choice. I did almost all my qualification appointments via zoom so it didn’t really matter.

Remember, insurance has a goal of never paying for anything, so they make the whole process a pain in the butt on purpose to save money by weeding people out. I am a very stubborn and goal driven individual so I enjoyed checking off all the boxes and seeing them have to approve my prior authorization in the end. Make ‘em pay!