Does this make sense? Q about insurance and my doctor.

[Mercury.Belle 8]

I hope this is the right place to post this question!

I have Molina Medicaid Apple Health insurance. Two weeks ago I brought up bariatric surgery to my doctor. I even brought a copy of the Molina Medicaid Apple Health pre-surgical assessment form that she is supposed to fill out and fax. She is 100% on board with me having this surgery from what I can tell, so that isn’t the issue. And she seems really nice, I only just started seeing her.

On Monday I sent her a message asking if she had sent in the form and asking what happens when they approve/deny it and she responded that she hadn’t yet. After a few misunderstandings of the actual criteria Molina has for surgery, I sent her a message that Molina sent me when I asked them directly. I qualify based just on my BMI according to what they told me. She said that helped and she would send the form the following day. Great! Except now she’s saying she was told by the dietitian at the clinic that it isn’t her who sends the form in, it’s the dietitian. At this clinic, they like to have all of the appointments set up BEFORE sending in that form for approval since stage 2 starts immediately upon approval. I sent her the PDF from Molina that outlines the stages and that it says my PCP has to send it before which she agreed made sense but she doesn’t want to go against what the clinic does. She also said she’s never been through this process before, so I guess I’m her first patient to want this?

That isn’t right, is it? The dietitian can’t fax that form, can they? At my appointment two weeks ago my doctor sent in a referral for the dietitian just so I could get on the books since we don’t know how long this process will take and I scheduled an appointment for next month knowing I might have to reschedule. But now my doctor is basically saying the form won’t be sent until I go to that appointment… but why would I go to that appointment if it won’t count?

Should I find a new doctor? Or should I trust they know how to do things? Should I call Molina and ask? I’m a nervous person in general and this isn’t helping. 😂 I just don’t want this to get messed up!

Sorry for the long post.

[BabySpoons 632]

I know all insurance companies differ but my first step was contacting mine to make sure I was covered and how much coverage I had. Secondly, which doctors are listed as in network. If you go to one that is not, you will be paying more out of pocket. When I decided on which Bariatric team to go with, I called them directly and asked if I needed my GP's referral first before my initial consultation. They said no, so I was set up with my first appointment with them. Since it was out of town, they would set up all my follow up appointments for nutritionist, surgeon, psychologist and nurse, all on the same day to cut down on my driving miles.

What's nice about having a team that specifically does Bariatric surgeries is they made all my post-op appointments for me including any testing that I needed done locally. Also they submitted everything to insurance for me and any pre-authorizations needed. I didn't need to even think about it.

It's stressful enough to initially make the decision to have the surgery without the added worry of having to figure out all of the process. Good luck and hope it all will get sorted out for you soon.

[Jeanniebug 476]

I think it's interesting that you will be meeting with the Dietician before meeting with the surgeon. I'd go ahead and do it however the clinic wants it done. If the Dietician usually sends it, then let her.

[Arabesque 7,595]

American health insurance is crazy to me but would it matter if both your doctor & the dietician sent in the form? I mean your doctor would provide the most relevant information about the benefits of the surgery to you medically in regards your health status while the dietician would provide information in regards to your eating & nutritional needs. 🤷🏻‍♀️ If your insurance says your doctor sends in the form they should send in a form. It’s the insurance company approval you need not the clinic’s.

[Mercury.Belle 8]

Thank you for your replies! I’m going to call my insurance tomorrow to ask them about it and see if what my doctor is saying will work. 🙂

[New To This23 102]

On 5/21/2023 at 12:14 PM, Mercury.Belle said:

Thank you for your replies! I’m going to call my insurance tomorrow to ask them about it and see if what my doctor is saying will work. 🙂

Did you get this straightened out? I can tell you that your PCP sends the form in. Then you set up 12 Dietician Visits, 6 weight, and BP checks with your PCP or nurse, a sleep study if you are not already using a CPAP, if you are not using a CPAP and they say you have sleep apnea, you are going to have to get set up with at and be compliant with it. When you get closer to finishing your Dietician appointments, you will schedule a psychosocial appointment. Once all of that is completed and you met the goal weight Molina has set for you then you will be referred to the Bariatric clinic. You will meet the surgeon and then do any assessments they have (this will vary from person to person). Then you will get your surgery date.

The nice thing about Molina is you will get your own case manager, who will explain everything to you. You can call them anytime. They will let you know every step and piece of paperwork and who handles what and when. They will also periodically call you to check in on you. This case manager is so helpful, because PCP and dieticians do not seem to totally understand the process, and it's because Bariatric is not their specialty, not until you get to the clinic.

So stage one, your PCP fills out the form and submits it to your insurance

stage two you do all of the appointments and hit the goal weight Molina gives you (Your case manager will call and introduce themselves, plus you will get a letter in the mail. Your case manager is also a nurse and they will ask your weight so make sure the DR puts down an accurate weight, if not petition to have Molina change it)

stage three you move on to the clinic and get surgery.

[New To This23 102]

On 5/21/2023 at 12:14 PM, Mercury.Belle said:

Thank you for your replies! I’m going to call my insurance tomorrow to ask them about it and see if what my doctor is saying will work. 🙂

Did you get this straightened out? I can tell you that your PCP sends the form in. Then you set up 12 Dietician Visits, 6 weight, and BP checks with your PCP or nurse, a sleep study if you are not already using a CPAP, if you are not using a CPAP and they say you have sleep apnea, you are going to have to get set up with at and be compliant with it. When you get closer to finishing your Dietician appointments, you will schedule a psychosocial appointment. Once all of that is completed and you met the goal weight Molina has set for you then you will be referred to the Bariatric clinic. You will meet the surgeon and then do any assessments they have (this will vary from person to person). Then you will get your surgery date.

The nice thing about Molina is you will get your own case manager, who will explain everything to you. You can call them anytime. They will let you know every step and piece of paperwork and who handles what and when. They will also periodically call you to check in on you. This case manager is so helpful, because PCP and dieticians do not seem to totally understand the process, and it's because Bariatric is not their specialty, not until you get to the clinic.

So stage one, your PCP fills out the form and submits it to your insurance

stage two you do all of the appointments and hit the goal weight Molina gives you (Your case manager will call and introduce themselves, plus you will get a letter in the mail. Your case manager is also a nurse and they will ask your weight so make sure the DR puts down an accurate weight, if not petition to have Molina change it)

stage three you move on to the clinic and get surgery.

[Mercury.Belle 8]

On 6/13/2023 at 7:48 PM, New To This23 said:

Did you get this straightened out? I can tell you that your PCP sends the form in. Then you set up 12 Dietician Visits, 6 weight, and BP checks with your PCP or nurse, a sleep study if you are not already using a CPAP, if you are not using a CPAP and they say you have sleep apnea, you are going to have to get set up with at and be compliant with it. When you get closer to finishing your Dietician appointments, you will schedule a psychosocial appointment. Once all of that is completed and you met the goal weight Molina has set for you then you will be referred to the Bariatric clinic. You will meet the surgeon and then do any assessments they have (this will vary from person to person). Then you will get your surgery date.

The nice thing about Molina is you will get your own case manager, who will explain everything to you. You can call them anytime. They will let you know every step and piece of paperwork and who handles what and when. They will also periodically call you to check in on you. This case manager is so helpful, because PCP and dieticians do not seem to totally understand the process, and it's because Bariatric is not their specialty, not until you get to the clinic.

So stage one, your PCP fills out the form and submits it to your insurance

stage two you do all of the appointments and hit the goal weight Molina gives you (Your case manager will call and introduce themselves, plus you will get a letter in the mail. Your case manager is also a nurse and they will ask your weight so make sure the DR puts down an accurate weight, if not petition to have Molina change it)

stage three you move on to the clinic and get surgery.

Hello! Yes, I did. The pre-approval was sent by the dietitian but it was apparently listed as coming from the doctor. At this clinic the doctor and dietitian work together to do this, I guess. I got my approval today to start stage 2!

[New To This23 102]

On 6/26/2023 at 3:16 PM, Mercury.Belle said:

Hello! Yes, I did. The pre-approval was sent by the dietitian but it was apparently listed as coming from the doctor. At this clinic the doctor and dietitian work together to do this, I guess. I got my approval today to start stage 2!

Great!! my advice is to get everything you can scheduled in advance and do not be afraid to advocate for yourself. For example, Molina wanted me to complete everything from stage 2 by June 23rd. The Dietician was the hardest to get on the schedule with, and I was just under 2 months into the program before I could get in to see her. Which meant I was not going to meet Molina's goal of having everything completed by June 23rd. So I called my insurance and was told as long as I had been going to my appointments and staying on track they could extend the completion time. Well, I was still worried so after a few visits with the Dietician I asked if I could get the 3 appointments that were scheduled through the end of July changed they were able to adjust things and I finished my appointments on June 13th.

Now I am meeting with the Surgeon tomorrow!!

[Mercury.Belle 8]

13 hours ago, New To This23 said:

Great!! my advice is to get everything you can scheduled in advance and do not be afraid to advocate for yourself. For example, Molina wanted me to complete everything from stage 2 by June 23rd. The Dietician was the hardest to get on the schedule with, and I was just under 2 months into the program before I could get in to see her. Which meant I was not going to meet Molina's goal of having everything completed by June 23rd. So I called my insurance and was told as long as I had been going to my appointments and staying on track they could extend the completion time. Well, I was still worried so after a few visits with the Dietician I asked if I could get the 3 appointments that were scheduled through the end of July changed they were able to adjust things and I finished my appointments on June 13th.

Now I am meeting with the Surgeon tomorrow!!

All of my PCP appointments are now scheduled. My first appointment with the dietitian is on Friday, so hopefully she’ll be able to schedule all visits at that time.

Yay, that’s awesome! Where are you getting your surgery done at?

[New To This23 102]

11 hours ago, Mercury.Belle said:

ay, that’s awesome! Where are you getting your surgery done at?

Rockwood in Spokane, Wa.