Tricare Prime - Lap Band Denied Again, Again, And Again!

[54Shirley 105]

Hi Shirley-- I know you are trying to be helpful and agree that the insurance game isn't fair to us consumers-- I absolutely will not argue with that I just disagree that it's good to publicly encourage people to commit a crime: it's more than lying, it's lying you can be punished for financially and it's a lie that hurts everyone else who doesn't lie. That doesn't seem fair either. It's a bad situation, all around-- well, for everyone except the insurance giants I guess.

I understand you totally ! I really do !

After the kickbacks from the Dr.'s to the Ins. Company's, and O yes there is, and we pay higher Ins prices every year.

I no it's morally, and ethically wrong, But who's going to say something ? YOU ! I don't think so...

Let me tell you something.

When I switched surgeons. They were really very Leary of taking me on.

After all I was Roux n y patient. WHAT? I said I have the Band. No you had the bypass done on 10/31.06. Yes that was my band date. Take a look at my weight loss History, and that should show that at 1-2lbs. a week, that it is the band.

"YOU KNOW,,,, WE WONDERED WHY THEY DIDN'T SEND YOUR WEIGHTS ?

Duh ! Hello, I didn't have that surgery.

So under Fluoroscopy I went, and sure enough I was banded. BUT,,,,, that sob billed the ins. co. for the other surgery, and I am sure he has his favorite person to bill threw, and they see a kickback.

His Insurance Nurse was a big crook, and busted at several different Hospitals for Ins. Fraud.

He is still kicking, and doing his own thing. I just wonder how many years before me, has this been going on.

They won't doubt him. Henry Ford is a Center Of Excellence in Detroit, and he is Chief Surgeon. So he is big boss, what he says goes. My new Dr. is a student of his. He asked me who was the biggest pain in the *ss Him or his nurse? Well I knew she was a pain, but it was him causing all the problems. So they believe me, and they don't treat me like Sh*t, like he did.

I get where your coming from, and I understand your clear thinking. But when you find out that they are ripping the Ins. co. of, and you mean nothing now, because out with the old, and in with the new patient, and that's all that matters..

Then are rates go up ! I still say why shouldn't she.? They are not going to miss that at all.

I would rather see someone who needs it get it. Then a Surgeon ripping the system off. Add how many surgeries a day also.

[Joleen 3]

I am also tri care prime and barely made the requirements!!! You can request a "special hearing" I think that's what it was called! I was almost denied, and became hysterical at 5pm the friday before my surgery, my MD office called to tell me the insurance company called them to tell them there where problems and they wanted more information!!!! Thank goodness they had super office people and the job got done and I got my surgery Monday morning!!!!

Tricare is never is to deal with that is why they aren't accepted in many doctors offices!!!

Good luck!!

[Dave_NW 92]

I am also tri care prime and barely made the requirements!!! You can request a "special hearing" I think that's what it was called! I was almost denied, and became hysterical at 5pm the friday before my surgery, my MD office called to tell me the insurance company called them to tell them there where problems and they wanted more information!!!! Thank goodness they had super office people and the job got done and I got my surgery Monday morning!!!!

Tricare is never is to deal with that is why they aren't accepted in many doctors offices!!!

Good luck!!

Tricare is actually one of the easiest to deal with because their requrements are so specific. If you meet the requirements, you'll get approved. If you don't meet the requirements, you won't get approved. There is no middle ground. The only time I've ever heard of someone being denied by Tricare is if they either don't meet the requirements, or if the paperwork gets messed up. (But once it gets straightened out, the person gets approved, if they meet the requirements.) In my case, I had my approval within three business days of submittal.

The biggest reason Tricare isn't accepted by a lot of doctor's offices is because they won't pay for highly inflated billings. In the case of my surgery, the hospital and surgeon's office billed Tricare more than $75000 for my surgery. Tricare paid them $12000. The medical office has to be willing to accept what Tricare pays, and many of them don't want to do that.

Dave

[GoSetReady 0]

Tricare is actually one of the easiest to deal with because their requrements are so specific. If you meet the requirements, you'll get approved. If you don't meet the requirements, you won't get approved. There is no middle ground. The only time I've ever heard of someone being denied by Tricare is if they either don't meet the requirements, or if the paperwork gets messed up. (But once it gets straightened out, the person gets approved, if they meet the requirements.) In my case, I had my approval within three business days of submittal.

The biggest reason Tricare isn't accepted by a lot of doctor's offices is because they won't pay for highly inflated billings. In the case of my surgery, the hospital and surgeon's office billed Tricare more than $75000 for my surgery. Tricare paid them $12000. The medical office has to be willing to accept what Tricare pays, and many of them don't want to do that.

Dave

Hey Dave,

I've noticed you are really active on this site. I wanted to give you the link to the new requirements so you could pass it on. It was approved on 2/14 and went into effect on 3/?/2011. Here it is: http://federalregister.gov/a/2011-3207 I've noticed Tricare hasn't updated their website with this correct info. Might help someone get approved who is having difficulty.

Regards,

Marcille

[GoSetReady 0]

The effective date is 3/16/2011.

[blackmajyk 7]

I wish you luck, do you have anything else that can fray the cost, like a hernia? My dr put in to tricare and i was approved same day. I am with tricare south and i heard they are pretty good at doing the approvals.

Ann

The effective date is 3/16/2011.

[SkinnyCL 0]

Wow! Thanks to everyone that has replied! I love the passion and sincerity of everyone! My BMI is 35 and the new rule will cover BMI from 35 - 40 and above. My doctor is one of the best and has done everything to help me out. I'm going to wait another month and try one more time. I heard from someone very helpful today that the new ruling might take affect at the end of July. So fingers crossed! Again, thank you for all the support! Many losses to all and happy lives!!

[SkinnyCL 0]

'AZArmyWife36' I'm so sorry for your denial if you're going to self pay I'm sure you probably already know this but just in case most base hospitals will do the procedure at a greatly discounted rate. For instance a Tummy Tuck that I was looking into years ago on base they quoted me $800 instead of the national average of anywhere from $6000 to $12000 . Hope this helps you a little. I know it sucks to be self paying. Best of luck and thank you to you and your family for all of your sacrifices!

Former USAF (ex wife)

[Navywif99 0]

I have Triwest and my info was just submitted to Tricare for approval and they are asking for more information. Based on the original information I am more than 100lbs over weight with diabetes which I take meds for and they still want more information. My BMI is like 41.

Somewhere along the line it was mentioned that I have knee pain now they want information from my pcm or orthopedic surgeon about my arthritic knees. They are also saying there isn't enough info in my file at Tricare but that is because the past 8yrs I have had a civilian pcm but I didnt think that would be an issue. Because Tricare doesn't keep their info updated they are also saying that New Hope where the surgery will be done isnt covered but as of June it is. How do they not know that and why do I have to prove to them that New Hope is a covered shouldn't they know that. So much for smooth sailing...

I thought since I met their requirments I would be instantly approved. Ive called Tricare but havn't spoken to anyone who can help me they just tell me to do what I need to do basically but to hurry up cause in 2 days it will be kicked back and I will have to start over. Awesome!

[54Shirley 105]

Look the place up on line, and see if you can get a printout of their Bariatric Center. If so Print a couple of them. Call your Ins. Co back, and tell them how to get to the site, that you printed. This way you can follow up on what they say they are looking at. That is proof. Then tell them you will gladly mail them a copy for your Records, to keep this smooth sailing. Also contact the Hospital, and get a hold of their Bariatric Center. Tell them your situation, and that you need proof that they exist as a Bariatric Center, So could they help? They will either send you info. on themselves or fax it. See if they will call someone for you also.

If they know you,and you have a name and number of someone who you were dealing with, they might do that for you.

Do you know if they are going to be a CENTER OF EXCELLENCE? A lot of Ins. Companies only work threw them. If they are? you need them to tell you, and them that they are one.

Good Luck, Shirley.

Also on your post, I see you have your Dr. up there. Click on your Dr., and print out her info. ... That to is proof.

[drowsyrn 0]

Hey Dave,

I've noticed you are really active on this site. I wanted to give you the link to the new requirements so you could pass it on. It was approved on 2/14 and went into effect on 3/?/2011. Here it is: http://federalregister.gov/a/2011-3207 I've noticed Tricare hasn't updated their website with this correct info. Might help someone get approved who is having difficulty.

Regards,

Marcille

Thanks so much for this information! I am just beginning my process and appreciate factual info.

[AZArmyWife36 0]

Winner!! Tricare has finally approved me! The new requirements have taken affect. They no longer use that crazy MET life chart. They'll be using your BMI. I have been denied at least three times and now it's my time! Good luck to all! Get healthy and be happy!!!

[MelindaH 3]

Winner!! Tricare has finally approved me! The new requirements have taken affect. They no longer use that crazy MET life chart. They'll be using your BMI. I have been denied at least three times and now it's my time! Good luck to all! Get healthy and be happy!!!

Yea =,you for being so persistent. Let us know when you are scheduled. I am married to a federal employee and very grateful for the coverage we have.

For the life of me, I do not understand why our military families can not be under the same coverage. End of rant....

I wish you all the best in your journey to good health.

Melinda

[Pashion 7]

Winner!! Tricare has finally approved me! The new requirements have taken affect. They no longer use that crazy MET life chart. They'll be using your BMI. I have been denied at least three times and now it's my time! Good luck to all! Get healthy and be happy!!!

I am glad that you have been approved because I have the same situation my BMI is 38.6 and the nutritionist told me that I would prob be denied because I have to have a BMI of 40 + one co-morbit, but now I see that is not true. One other thing I was also told by the insurance coordinator at the surgeons office that because they are civilian there is a chance that Tricare might come back and say that they will only approval the surgery if I go to my local MTF to have it done. Do you or anyone else reading this knows anything about this?

[AZArmyWife36 0]

I am glad that you have been approved because I have the same situation my BMI is 38.6 and the nutritionist told me that I would prob be denied because I have to have a BMI of 40 + one co-morbit, but now I see that is not true. One other thing I was also told by the insurance coordinator at the surgeons office that because they are civilian there is a chance that Tricare might come back and say that they will only approval the surgery if I go to my local MTF to have it done. Do you or anyone else reading this knows anything about this?

Hi! I have Tricare Prime. I went to my PCM on post and she gave me a referral to a bariatric doctor off-post. I saw a nutrisionist and did a pysch eval. Plus you should have some form of weight loss program you followed. I did Jenny Craig and HCG. Never did anyone say that I had to go on post or MTF to have it done. I'd call Tricare and ask about it. Good Luck!