Switching doctors pre surgery and tricare standard copay!

[arks 0]

Hello, I am new to this site, and I have a few questions regarding lap band and Tricare standard.

First, I want to say that I have been in this process for 3 months now, on Monday I have my last dietitian appointment until they submit all the paperwork to Tricare. I am 4’9” and weight 208lbs. I have 2 co-morbidities and I also meet the 200% weight requirement. So I am confident I am going to be approved.

My first question is regarding SWITCHING DOCTORS PRE SURGERY. I didn’t know I had to get a Tricare physician, so I just went to one I found on my own and I have just found out that I might be stuck with self paying the private surgeon. So, can I switch doctors before submitting the paperwork to Tricare? Do I have to start over? Do I change doctors after Tricare approves?

My second question is regarding TRICARE STANDARD COPAYS. I thought lap band surgery was going to be covered 100% Now I have read that I might be paying up to 1,000 out of pocket. Is that true? How much money out of pocket did you have to pay with TRICARE STANDARD.

Thanks in advance! I look forward to meet you all! I really need support while going through this!

[L12 13]

You should probably switch doctors NOW to avoid any issues with authorization, coverage, or hefty bills.

There was a mixup at the hospital regarding my insurance coverage, but at one point they had me paying almost $2400 dollars to meet the catastrophic cap ($3000) for Tricare Standard (the catastrophic cap amount depends on if you're considered active duty or "other"). Since I actually have Tricare Reserve Select, my catastrophic cap is $1000 dollars, so I really only owed a little over $600; the hospital finally issued me a refund three months later. Though Tricare covers 100% of the cost, supposedly that only happens after you have paid the deductibles and copays up to the catastrophic cap. I had paid about $400 in deductibles and copays the year of my surgery, so they covered the other $600 up to my catastrophic cap.

However, I have seen a lot of Tricare peeps on here say that they had no out-of-pocket expenses with Standard. I don't know if they already met their caps, or if they had surgery at a military hospital (which I think lowers/eliminates some/all fees?), but according to official Tricare policy, you owe the copay and deductible up to your catastrophic cap.

With that $2400 mixup I had for my surgery, I did a lot of research into Tricare policy--hopefully it helps!

[arks 0]

You should probably switch doctors NOW to avoid any issues with authorization, coverage, or hefty bills.

There was a mixup at the hospital regarding my insurance coverage, but at one point they had me paying almost $2400 dollars to meet the catastrophic cap ($3000) for Tricare Standard (the catastrophic cap amount depends on if you're considered active duty or "other"). Since I actually have Tricare Reserve Select, my catastrophic cap is $1000 dollars, so I really only owed a little over $600; the hospital finally issued me a refund three months later. Though Tricare covers 100% of the cost, supposedly that only happens after you have paid the deductibles and copays up to the catastrophic cap. I had paid about $400 in deductibles and copays the year of my surgery, so they covered the other $600 up to my catastrophic cap.

However, I have seen a lot of Tricare peeps on here say that they had no out-of-pocket expenses with Standard. I don't know if they already met their caps, or if they had surgery at a military hospital (which I think lowers/eliminates some/all fees?), but according to official Tricare policy, you owe the copay and deductible up to your catastrophic cap.

With that $2400 mixup I had for my surgery, I did a lot of research into Tricare policy--hopefully it helps!

Thank you so much for replying! I called a Tricare approved doctor today and they told me to go to my last dietitian appointment and then tell them I want to transfer to the new doctor. Whew! I already met my catastrophic cap, so hopefully I don't have to pay much!

[Daniboo424 0]

Hi,

I think that you and I have run into a similar situation and what I have discovered is that this company is basically ripping off military people. They do not tell you initially that you need to have a referal from a Tricare doctor because they are not within the network to be covered by Tricare.

They are supposed to get preauthorization for all of their procedures before they do them, because that is what they tell you they will do before you come in, but the fact is they do not do this. They submit everything after you have already come in hoping that Tricare will approve it.

As you have stated you are well within the ramification of what is acceptable for this type of surgery so you would do better to just get a Tricare doctor. Do you live in an area where you can use civilian healthcare? I live outside of the limits of where military facilities are accessible so I am authorized to use civilian doctors to be seen as my primary care manager (PCM). Your PCM is the person that will give your the referal so that you can have the authorization to have lapband at no cost to you. I just had all of this done about 2 weeks ago. I have an appointment the first week of next month with a new doctor. I'm not starting over completely, but it has delayed the date of the actual surgery. The bright side to all of this is that I do not have to pay a co-pay and no out of pocket expense.

If you choose to stick with the doctors you are currently with you will have to pay up to the cap and then 50% of whatever Tricare does not cover that is way that it is set up. That is you using your POM rights. So its up to you the way you wish to go, but I would definitely choose free over paying any day. feel free to write me back with any questions and I'll try to respond as best I can. I hope I've helped.

- Dani

[arks 0]

Hi,

I think that you and I have run into a similar situation and what I have discovered is that this company is basically ripping off military people. They do not tell you initially that you need to have a referal from a Tricare doctor because they are not within the network to be covered by Tricare.

They are supposed to get preauthorization for all of their procedures before they do them, because that is what they tell you they will do before you come in, but the fact is they do not do this. They submit everything after you have already come in hoping that Tricare will approve it.

As you have stated you are well within the ramification of what is acceptable for this type of surgery so you would do better to just get a Tricare doctor. Do you live in an area where you can use civilian healthcare? I live outside of the limits of where military facilities are accessible so I am authorized to use civilian doctors to be seen as my primary care manager (PCM). Your PCM is the person that will give your the referal so that you can have the authorization to have lapband at no cost to you. I just had all of this done about 2 weeks ago. I have an appointment the first week of next month with a new doctor. I'm not starting over completely, but it has delayed the date of the actual surgery. The bright side to all of this is that I do not have to pay a co-pay and no out of pocket expense.

If you choose to stick with the doctors you are currently with you will have to pay up to the cap and then 50% of whatever Tricare does not cover that is way that it is set up. That is you using your POM rights. So its up to you the way you wish to go, but I would definitely choose free over paying any day. feel free to write me back with any questions and I'll try to respond as best I can. I hope I've helped.

- Dani

Thanks for your post, it was really helpful, I sent you a PM though

[Dave_NW 92]

I have Tricare Prime, which is run a bit differemtly than Tricare Standard, but I went through something similar. I had initially contacted a local WLS center to see about surgery. I attended a seminar, and got all ready to move forward. Then I learned I needed a referral from my PCM. So I went to the PCM, got my referral, went back to the WLS people, only to find out they don't accept Tricare at all. If I had continued, I'd have had to pay it all out of pocket.

Back to my PCM. After calling around, I found an experienced WL surgeon who accepted Tricare. Got another referral from my PCM to that doctor, and I went to an introductory appointment. He was great, everything looked good, except for the teensy detail nobody had mentioned - his clinic wasn't approved for actually DOING the surgery. They took Tricare, but apparently Tricare hadn't approved them. So, here I go again...

Third try: I found an approved hospital surgery center with an approved doctor, and got a third referral. Went to see them, and had a very frank conversation with their insurance referral coordinator. I wanted to be absolutely clear that everything I needed to be covered WAS covered. And it was.

I was banded three weeks ago, and based on the Claims page at Tricare, it looks like everything the hospital is billing Tricare for is being approved. It'll be interesting to check the bottom line to se how much the hospital bills vs. how much Tricare pays.

Good luck with your journey, and with your surgery.

Dave

[arks 0]

I have Tricare Prime, which is run a bit differemtly than Tricare Standard, but I went through something similar. I had initially contacted a local WLS center to see about surgery. I attended a seminar, and got all ready to move forward. Then I learned I needed a referral from my PCM. So I went to the PCM, got my referral, went back to the WLS people, only to find out they don't accept Tricare at all. If I had continued, I'd have had to pay it all out of pocket.

Back to my PCM. After calling around, I found an experienced WL surgeon who accepted Tricare. Got another referral from my PCM to that doctor, and I went to an introductory appointment. He was great, everything looked good, except for the teensy detail nobody had mentioned - his clinic wasn't approved for actually DOING the surgery. They took Tricare, but apparently Tricare hadn't approved them. So, here I go again...

Third try: I found an approved hospital surgery center with an approved doctor, and got a third referral. Went to see them, and had a very frank conversation with their insurance referral coordinator. I wanted to be absolutely clear that everything I needed to be covered WAS covered. And it was.

I was banded three weeks ago, and based on the Claims page at Tricare, it looks like everything the hospital is billing Tricare for is being approved. It'll be interesting to check the bottom line to se how much the hospital bills vs. how much Tricare pays.

Good luck with your journey, and with your surgery.

Dave

Wow! Quite an ordeal! But it was all worth it I see =)

Well, I am going to keep my last dietitian appointment on Monday, and then tell them I found another doctor (on Tricare's page so tricare should be ok with him) and transfer all the paperwork to this new doctor. Hopefully that can be done, and hopefully I won't experience any delay on the process. I definitely don't want to be stuck with bills or copays, so I guess I just have to be more patient. It's been 4 months since I started this process and it feels like an eternity. I am so glad I found this board, now I don't feel so alone and clueless about this! I'll keep y'all posted!