Hello All,

I am new to the bama forum, I am Michelle and I live in Anniston. I am looking to have lap band surg. probably in May with Dr. Schmitt in Birmingham. I have been to the free seminar, going to the support group meeting this Sat. for Lap Band, and I have my first appt. with Dr. Schmitt April 10th. I have Federal BC/BS which appears to be very different from regular bc/bs of alabama regarding the requirements.

I would appreciate any suggestions or advice as I begin this journey. Would love to hear from anyone who has used Dr. Schmitt or Dr. Miles too.

:biggrin2: Michelle

hello i am from hamilton, Al i had the lap-band done on feb 6th i used dr.ronald Clements at uab he is a great dr. i also have a dif bcbs other than alabama mine is anthem bcbs of virgina all they reqired was doctor weigh ins for 3 years and that i see a phychatrist. i had no problem with my ins.maybe you want either good luck keep us posted

Hi Michelle and WELCOME! I really don't have any advice to offer as I have been to the same seminar as you and the info. would be the same! :smile: However, there are several who post here that have used the Miles/Schmitt group so I am sure you will be hearing from them soon! Good luck and, again, WELCOME!!

I'm using Dr. Miles. 4/24/08 is the date! Can't wait!

Yes, Dr. Clemments is an excellent surgeon at UAB. I have heard excellent reviews from the medical community and past patients of his. Keep me posted with how you are doing.

Michelle

Hi there. I used Dr. Schmitt and also have Fed BCBS. I have the basic option, and got hit with some unexpected co-pays....but cant complain too much, bc it was still much much less than some folks have to pay. Not sure what option you have, but if you can manage to get the surgery done as an inpatient, it is much cheaper.

I have standard federal bc/bs. Did you stay overnight? I am really wanting to come home the same day. With the federal bc/bs did you have to jump through lots of hoops. According to the new "annual" fed. bc/bs policy book you get in jan. of each year ( gives you all the changes) if you have a bmi of 40 or more without comorbid. or bmi 35 and above with comorbid, you qualify. I have a bmi of 43. were you able to get the required evals. nutrition, psych, and lab test within a decent turn around time or did you feel it just was just dragging out forever before you acutally got your surgical date and did you have a good post-op experience, like waking up in recovery how did that go? Sorry I have so many questions but finding someone with federal bc/bs and the same doc is like hitting the lottery for me to ask questions since I am just so ready to get to the post op part of life....

Thanks so much for any help,

Michelle

Ask all the questions you can think of...I will be glad to answer.

It really didnt seem like there were alot of hoops that BCBS required. Dr. Schmitts office sent them a letter, or to be more correct, filled out a standard form that BCBS uses. The form explained my history and current status of obesity. About three weeks after that I got a letter from BCBS stating that as long as my condition did not change from what was stated on the form, the surgery would be considered medically nessacarry. This is different from pre-approval, but it didnt cause me any issues.

Now, Dr. Schmitts office did require a few hoops:

1. letter of being "fit for undergoing surgery" from my PCP. Very easy to get, as I am healthy as a horse, cept for being fat lol

2. Evaluation for sleep apnea. This area proved to be a huge holdup for two reason: First of all, it seems to be really hard to get an appointment with these folks! And then, its hard to get an appointment for the sleep study. And then you have to wait forever to get the results, etc, etc. Second, I think I messed up by not going to see one of the sleep docs recommended by Dr. Schmidts office. I didnt wanna drive to Bham for this, so I chose a local doc. My doc didnt seem to understand what kind of documentation Dr. Schmidt needed. So that was a pain and took forever!!! I highly suggest getting this out of the way first thing.

These were the only two medical hoops I had to jump through. A psych eval was not required. Also you have to attend a lapband support group meeting and a nutrition class, but those were no problem to schedule.

I did my surgery outpatient and felt fine going home that day, even if there was a two hour drive back to Huntsville. BUT, I was I had done it inpatient. Even though the surgery was covered no problem, different levels of copays apply to inpatient than outpatient. For example, if you look in the benefits book you mention, look at the benefits for durable medical equipment, which is what the band and port system is considered. If you do inpatient, it is covered 100% with no copay, but the same equipment is subject to a 30% copay if its implanted during outpatient surgery. That alone came to $1,600. Also, some of the drugs they give you before/during surgery fall under the same rules and arent covered as anthesia. Sorry for going on and on, but I was really surprised by the different levels of copays. If you have other questions or need me to put out what pages/sections these issues are on, send me a pm with your email...I wont bore the others on here lol.

Take care!

RCG

Thanks so much for explaining the difference bc/bs inpat vs. outpt. That really stinks that outpt. cost more out-of-pocket. That's so crazy, esp. about the sedating drugs. I am sure I will have more questions later.

Happy Easter,

Michelle

Sorry, I may not have been clear in my last post. The anthesia is covered 100% inpatient or outpatient. But they give you other drugs, such as anti-clotting medicine for example, that are only 70% covered for outpatient.

The ENT Dr. Schmitt recommends for the sleep study, is his sister, Dr. Kim Schmitt. Her office and the room where they do the sleep study is there at St. Vincent's East. I had my appointment with her within days of my first consult and the study the next week.

OK... Help Please--- I called BC/BS PPO last month and they said my surgery is covered. I assumed (and evidently this is a good example of where that gets you...) that everything would be covered whether as outpatient or inpatient surgery. Can someone who knows please straighten me out on this? Will Dr. Schmitt's office give me a breakdown of any out of pocket costs? Thanks so much!!!

OK... Help Please--- I called BC/BS PPO last month and they said my surgery is covered. I assumed (and evidently this is a good example of where that gets you...) that everything would be covered whether as outpatient or inpatient surgery. Can someone who knows please straighten me out on this? Will Dr. Schmitt's office give me a breakdown of any out of pocket costs? Thanks so much!!!

What you were told is correct, everything is COVERED...but the way things are covered differ between inpatient and outpatient. I dont think Dr. Schmitts office can give you a breakdown, b/c they dont bill for the hospital. The way I was billed was one bill from Dr. Schmitt for the surgery (covered at 100% with only a small copay to deal with), one bill from the hospital (multiple line items on this bill, everything from different meds to the band itself, to the recovery room. Many of These items were only covered at 70% due to outpatient status), and finally the anthesia bill, which should be covered at 100% no matter if surgery is in or outpatient.

I'm speaking from MY own experience. You should call BCBS and get them to explain to you how your benefits differ between in and outpatient surgery. The part that I guess threw me for a loop was I thought I would only be charged the $16K or so they quote at the seminar as the cash price, and that benefits would apply to that. If you have insurance, that is NOT the case, there are MANY seperate charges and thus all of the different rules by which insurance will apply. BUT at least we have insurance, right? I bet that is as clear as mud, right? Send me a pm if you have any specific question.

The ENT Dr. Schmitt recommends for the sleep study, is his sister, Dr. Kim Schmitt. Her office and the room where they do the sleep study is there at St. Vincent's East. I had my appointment with her within days of my first consult and the study the next week.

I really wish I had went with Dr. Kim Schmitt. It sounds like she was much easier to see than the folks I went to, even factoring in a two hour drive one way to get to her :biggrin:

Edited March 25, 200818 yr by Rocket City Guy
Clarity

Just wanted to see, did you look into Dr. Freeman in Anniston? I live in Huntsville, but I had Dr. Freeman do it. He is fantastic, I drive all that way just to do follow ups with him.

Good luck with the insurance :ohmy:)

Hey thanks so much for the added info. I have my first appointment to meet and talk with Dr. Schmitt on 4/10. The only 2 things that are making me worry (in the scope of getting the required things out of the way) are:

1. unecessary test such at sleep apnea study, I dont have any problems in this department. I have severe joint and lower back pain, hip, knees, and feet.

2. I only use an urgent care clinic if I get sick, I havent had a "family doc" in 10 years or more. I just hope he will accept the records from a clinic. Im not sure how this will if you have a letter from a primary care doctor.

Did Dr. Freeman require everyone to have a sleep study and a letter from your Primary care doctor saying you were ok for surgery?

Michelle

I didn't think I had sleep apnea either. I sleep like a baby. Evidently, I actually stop breathing A LOT and was diagnosed with severe sleep apnea. I'm glad I know this before going under anesthesia and that weight loss should correct it.

I wouldn't think where the records came from would be an issue. I assume different doctors are signing off each visit? Now, if you were having to go through the six month stipulation, you would have to be under one docotor's care.