So... I got my referral, then my approval and then a surgery date. I was going to be the first tricare lapband patient at the hospital.

I went for my pre-op today and a bomb was dropped on me. Apparently the hospital checked with tricare and found out how little they would pay and have decided not to take my insurance. Both the hospital and the doctor accept Tricare... but have decided not to take it for the lapband.

I feel a bit betrayed, by the hospital... but I do understand since apparently Tricare would only pay about $850 over the cost of the lapband. But, I wish they would have figured this out a few months ago before they led me along.

So, I am now shopping for a new surgeon. My surgery was scheduled for June 9... I will be lucky to get in to see a new surgeon by that date.

Does anyone who have Tricare have a copy of their explanation of benefits of what was actually paid for the surgery?

Kristina--

Did Tricare pay for your nutrionist appointments? The doctor's office told me that is all they won't pay for. Besides that, I have had to pay $12 for my 1st copay and of course, parking downtown.

they offered everything on post for free...psh. eval, nutritionist..everything!

Kitty, I have to agree with Fdiljn concerning Tricare. I have an actual person working on my authorization. I have her name and her direct phone number, and every time I've called her, I've heard back from her within a couple of hours!

Tricare can be hard to deal with at times, but I have been a military wife for 37 years, and it is better now than it has ever been. Tricare HAS to have an authorization processed - either approved or denied, within five business days. I've worked in doctor's offices, and have had coverage from private insurances, and do not know of a SINGLE other insurance that makes that kind of effort.

The biggest drawback with Tricare is that they pay less than other insurances! So, if you want to know why private insurance or other group insurances are so expensive...there's one of the reasons. Every state has an insurance board that sets acceptable pricing for procedures in that state. Tricare, and other federal insurance programs, like Medicare, pay at the low end of that scale. Doctors and hospitals always charge at the high end, and above, if they can.

Many Tricare employees are military; either a dependent or a retired member. They KNOW what we are dealing with. I have always been treated with utmost respect and courtesy. I'm sorry if you have not.

So... I got my referral, then my approval and then a surgery date. I was going to be the first tricare lapband patient at the hospital.

I went for my pre-op today and a bomb was dropped on me. Apparently the hospital checked with tricare and found out how little they would pay and have decided not to take my insurance. Both the hospital and the doctor accept Tricare... but have decided not to take it for the lapband.

I feel a bit betrayed, by the hospital... but I do understand since apparently Tricare would only pay about $850 over the cost of the lapband. But, I wish they would have figured this out a few months ago before they led me along.

So, I am now shopping for a new surgeon. My surgery was scheduled for June 9... I will be lucky to get in to see a new surgeon by that date.

Does anyone who have Tricare have a copy of their explanation of benefits of what was actually paid for the surgery?

Your doctor sucks... where are you located. I'm in Michigan and have had mine done through tricare... the trick is to find someone who is familiar with tricare already (a surgeon who had done gastric with them probably has idea of how cheap they are). They did not send me anything with how much they paid, I only get bills if something was filled out wrong (happens quite often). You might be able to talk to a case manager to find out the amount. Did you have a rep contact you... when you are scheduled for surgery they are supposed to assign you a person to take care of you through tricare, they may be able to help you. You may want to check out surgeons on lapband.com in your area... that's how I found my doc.

I have Medicare part B and Tricare-For-Life, and have decided to have the Band procedure. I'll probably get banded the last week of June.

I plan to get the Realize brand rather than the LapBand brand. Basically the same device, but it has a much lower profile fill-port.

I'm in the process of planning for surgery at either Banner Good Samaritan, or Bridges Weight Loss Center at St Lukes, in Phoenix, AZ, and have attended seminars at both facilities.

Those two are the only Centers of Excellence in AZ that have Bariatric surgeons contracted with Medicare & Tricare. DRs Hilario Juarez and Daniel Fang, both experienced, respected Bariatric surgeons, practice at both facilities.

I'm told that Dr Robin Blackstone, the sole Bariatric surgeon at Scottsdale Bariatric Center, the only other AZ Center of Excellence, has just recently ended her association with Medicare, so if you have Medicare, Juarez & Fang are the only two choices in AZ. For no particular reason, I'll probably go with Dr Fang.

Medicare, Tricare, the hospital, and both surgeons all assure me that Medicare will pay 80% of the cost, and Tricare the remaining 20%.

Excluded from their coverage are the surgeon's requirements (not Medicare, Tricare, or the hospital's requirements) for a Cardio eval, a Psych eval, and a Pulminary eval (required because I have sleep apnea). Also an optional $140 Nutrition consult.

The AFB hospital does not have those specialties on staff, so I got consults from my PCP & Tricare, and paid a $12 co-pay for each of those 3 outside visits.

There are some labs required, and if any are not covered by either program, I'll get them done at the hospital on base.

Unless there are some really hidden costs that I haven't discovered yet, I expect the procedure to cost me a total of $36.00.

It's my understanding that Tricare doesn't pay for banding except as secondary to Medicare, so having Medicare part B and thus Tricare-for-Life are a given, and then everything should be covered, but I could be mistaken.

If anyone out there has Medicare & TFL coverage, and has had the band procedure, please tell us about your experience, specifically your final out-of-pocket costs.

Thanks.

WOW! Long first post! :biggrin:

kristina,

This contradicts everything I was told by Tricare, both in their local office(s), and during 4 or 5 phone calls to Tricare, and to TriWest, the managers for Tricare-for-Life.

Understand your spouse is active duty, and you are Tricare Prime?

How are you swinging it?

Everyone whom I have spoken with over the phone don't seem to be the most capable. Which is why when I have a problem with them I go to the service center. Maybe I get the wrong people when I call, maybe I catch them on a bad day, but the past few times I have called, no one knew the answers to the questions I have asked. Then asking to speak with a supervisor hoping they knew the answer, I would get told that they would look up the answer (all I needed to do was switch doctors for a referral). When this happened before all they had to do was give me a list of doctors in the area, let me find one who would take me, then change the name on the referral when I call back. It took four phone calls to tricare yesterday, the first time they gave me pediatric doctors to call, once everything was straightened out, and I called them back to tell them the right doctor they put in a different referral code, and today they called me back wondering why I had four referrals to one doctor.....Maybe they aren't all morons, I will give them that, but I do seem to get the ones that are less compitent than others.

I've gotten nothing but outstanding help, both through calling the 800 number and in person at my base hospital when talking with the Tricare reps.

I have Tricare Standard. My surgeon is a preferred provider but I'm one of the last Tricare patients he is accepting. Apparently they don't pay enough for him to continue accepting TC patients. I was told that if the anesthesiologist isn't a prefered provider then I would be responsible for a certain percentage beyond what Tricare pays which could be up to 15% of the total cost. That scares me but I know it's a must.

Edited May 30, 200818 yr by Long2BFree

OogaBooga,

I think Tricare is supplementing Medicare for you, because any time there is another insurance, Tricare is automatically secondary. So, Medicare would pay first, and then Tricare will cover what is left of the allowable charges, which, if your providers accept, will mean you will not have further expenses.

I just copied this from the Tricare.mil site concerning coverage:

Gastric Bypass

TRICARE covers gastric bypass, gastric stapling and gastroplasty to include vertical banded gastroplasty and laparoscopic adjustable gastric banding (Lap-Band surgery) is covered only when the beneficiary meets one of the following conditions:

• Is 100 pounds over ideal weight for height and bone structure and has one of these associated conditions: diabetes mellitus, hypertension, cholecystitis, narcolepsy, Pickwickian syndrome, hypothalamic disorders or severe arthritis of the weight-bearing joints
  
• Is 200 percent or more over ideal weight for height and bone structure
  
• Has had intestinal bypass or other surgery for obesity and because of complications, requires another surgery (takedown)
  

TRICARE does not cover:

• Nonsurgical treatment of obesity, morbid obesity, dietary control or weight reduction
  
• Biliopancreatic bypass, gastric bubble or balloon for the treatment of morbid obesity
  

Last Modified: March 24, 2008

Having posted this, we all need to realize that there are differences between Tricare Prime, Prime Remote, Tricare Standard, and Tricare for Life, and your accessability to a military medical facility. And, anytime there is another health insurance in place, Tricare is secondary. If the first insurance doesn't cover gastric surgery, Tricare needs a letter of denial from the first insurance before they will cover anything.

So, as we compare experiences, we need to be aware of which Tricare coverage is being discussed, and what other circumstances effect the individual situation.

I have been paper-pushing and hoop-jumping since January, when I learned that Tricare would cover lap band, because my husband retires this Saturday. He started a civilian job in February, when he went on terminal leave. The civilian job has insurance that does not cover gastric surgery. Letter of denial has not yet been processed (see previous post about timeframe for Tricare approval) - Tricare coverage changes on Saturday - civilian insurance is in the process of doubling monthly premiums, so we are changing to a private Tricare supplement. This will probably mean that I will have to wait until after the first of July to get authorization, so that Tricare, and the supplement, will cover the costs. IF the letter gets processed, and IF I can see what our expenses would be with a different Tricare, and IF it is manageable, I'll push for surgery in June. Everything is done except the pre-op. Surgeon and hospital accept Tricare, and both have already done some pre-op exams and testing for me. Tricare has told me I qualify (how does one react to that information---'Congratulations! You are officially overweight enough that you need surgical help!') and that it is just a matter of getting the DEERS and Other Health Insurance issues resolved.

I worked for Tricare for 4 years as a RN health care finder. Have you called Tricare and told them about the hospital and doctor? I am not sure if it is legal to pick and choose what services they will accept payment for because they have a contract with Tricare. Like I said I am not sure if it is legal but it wouldn't hurt to call Tricare to find out. GOOD LUCK

I spoke to several people at Tricare the past few days. Even a participating provider can refuse to do a service that they believe Tricare does not pay enough for. So, basically since Tricare will not pay them enough for the lap band they will not perform the surgery.

I am going to call the hospital tomorrow and see if anything changed. I am not holding my breath.

Has anyone been able to have the lapband procedure done at MTF?

Choromom,

Good reply. You are correct. In my case (TFL), since Tricare is secondary to Medicare, it covers only the remainder that Medicare doesn't (80%/20%).

Banders that have had their banding covered fully by other Tricare plans (Prime, PLus, etc.) probably have Tricare as their only coverage.

Thanks for the reminder.

I just got my hospital bill. I have Tricare and the insurance was billed 34877.00 Tricare paid 6049.78 and the adjustment was 28827.22. I paid nothing except my psy and nutrientist. Out of pocket $500.

Has anyone been able to have the lapband procedure done at MTF?

You might be able to find that info by doing a search if you don't get any respones here. I was given the info for a MTF in Northern CA but it's a 6 hour drive away from me. I wanted to stay local.