No Prior Auth--Too Risky?

[Cate18 0]

I was wondering if anyone else has had this experience and would be willing to share. I have to pay 1/2 of the cost of my surgery, which will be approximately 10k out of pocket. I'm willing to do that if I have to. I've come to terms with it.

However, my insurance company won't let me do a pre-authorization for my surgery. The way it works is I have the surgery, then my doctor sends in all of my information and says, "Please pay for this". Then the insurance company decides.

Did anyone else have to do this ? Have any of you been denied ? Now...I'm willing to belly up 10k to the table, but to turn around and potentially have to pay another 10k, I don't think I could do that. I'm a grad student, and not the richest person in the world.

I'm relatively certain I'll be approved. My BMI is at least 40, I had a supervised program (Feb 2007 to Oct or Nov 2007), I have insulin resistance, polycystic ovarian syndrome, and hydradenitis.

Still....I'm nervous. Can anyone give me some insight ?

Thanks !

[RestlessMonkey 7]

That is atypical for modern insurance. Most preauthorize to control costs. I don't think I'd trust it. It's too easy for them to say "no"...then what recourse? And how much energy to fight?

[babbs3772 1]

Wow that really stinks, I have to agree with RestlessMonkey - that is really risky.

I am really sorry they are giving you an ultimatum essentially and that seems really unfair.

I am not able to answer your question (obviously) but I wanted to post and let you know that I am thinking of you, I hope someone will have the right answer for you so you can get moving with your surgery.

Good luck to you, Barbie

[Cate18 0]

Thanks to both of you for the kind words. I'm a bit upset because I can have gastric bypass without paying anything out of pocket, but I really don't feel like it's the right surgery for me. I just can't see myself risking owing 20k. I feel really torn right now.

[RestlessMonkey 7]

My insurance didn't cover lap band till this year. I had planned to self pay (15k or so) and found out literally weeks before that they DO PAY starting Jan 1.

If you want to self pay, you CAN shop around for GOOD surgeons who don't charge so much. There is one in Denver who charges under 10K, for example...depending on your situation that may be feasible for you. His name is Dr. Kirshenbaum (or Kirschenbaum...I've seen it both ways) You can do a search on him here and find many ready to praise him, although I have no personal knowledge of him.

AND you can call your insurance back, ask for a manager, and go over it all again. Pin down exactly WHAT criteria they will be needing to pay the balance, find out how many they've paid for, ask what their approval rate is.

Of course, you can concentrate on school, graduate, get a job, and then see where you land. There's nothing wrong with that, either.

[Cate18 0]

Okay...let me kind of ask a followup question now that I've had time to think this through. If any of you had found out that it was simply not possible to have LapBand surgery in your current means, and wouldn't be able to afford it for...say...6 more years (assuming you wrote a GREAT thesis :thumbs_up: ), would you have a RNY ?

Would you stick to your guns and say, "This is the right choice for me, and that's all I am willing to do" or would you say, "Anything is better than this (what I'm living with now)"

Not looking for anyone to make up my mind for me, but just wondering how others think they might react.

[daco525 0]

I thought about this, I think I would go with the gastric bypass. I am afraid to continue with the medical conditions associated with obesity, I fear a heart attack in the next 6 years.

[MacMadame 81]

I would never have RnY. I think the procedure has too many design flaws and there are better options out there.

Btw, do you have medicaid? I know they don't pre-authorize WLS, but I've not heard of others.

I see you have having a number of choices:

1) If your surgeon's self-pay price is less than $20k, work something out with him that, if you are denied for reimursement, you will pay him the self-pay price and not what he would normally charge insurance.

2) Self-pay somewhere else so that even though you are paying slightly more than 10,000, you know ahead of time what the cost is. My surgeon charges about $14,000 last time I checked and we are in a high COL area. You could probably get a band for about $12000 if you shop around and are willing to travel. You could also go to Mexico and pay around $7000.

If you go out of town, make sure you have a fill doctor lined up who will work on you when you get back, btw.

3) Research all the surgery types, pick the one you think is best for you, and self-pay for that through a medical loan. Btw, the sleeve is an excellent choice for self-pays because you get weight loss similar to RnY with much less complications and it's not that much more than a band upfront. Plus not having to get fills lowers your cost on the back end.

4) Do whatever insurance will pay for, but only if you do your research on that surgery and are sure it's going to work for you.

There are probably other choices but I can't think of them right now. :confused: