Warning For Those Just Starting The Lap Band Surgery Inquiry Process

[abqann 3]

I just want to give everyone heads up regarding insurance coverage. I spoke to my carrier BC/BS of New Mexico. They do cover lap band for patients with a BMI 35-40 who have co-morbidities, without a huge list of other hoops. That was the good thing I have been very excited because knew I was qualified and just had to wait it out.and go through the steps. I called again today and asked some more questions. What I found out is that even though those are the requirements for the insurance company , my employer has tacked on another more strict condition and you have to have a BMI of 40. No exceptions for co morbidities, or the fact that the plan covers it. I am so upset right now. ( crying of course ) So I either an sol or I would have to gain a minimum of 25 lbs to qualify. So I am basically out the $450 program fee I paid, and the $250 copay for the endoscopy. I was too upset when I spoke to the surgeons office to ask for a partial refund of the program fee. ( they will probobly remind me that it was non-refundable) Anyway just a heads up for those who are borderline, to not take the insurance companies or surgeons word without asking a ton of probing questions, and restating the information back to them, to make sure it is correct.

[Scooterbug 13]

Sorry to hear about that.....

Back in 2009 I was very excited to learn that the insurance company I had covered Lapband, so I went to a seminar and was about to set up an appointment to meet with a surgeon when I discovered my EMPLOYER (Verizon Wireless) did not cover it. Needless to say I was peeved.

Now in 2011 my wife is about to get insurance through her new job. It took alot of digging and calling different people (her HR department, UHC, UMR, etc) but we did verify that both the insurance and company cover Lapband. As far as our requirments my wife was told they would be the UHC requirments, so we have someone in her HR department trying to get us the EXACT information we need. I want to have every peice of info I can get involving requirments before I attend another seminar on the 16th.

In a case like yours I personally think the surgeon/doctor SHOULD refund all or at least 1/2 of what you paid them.

[Grider 92]

I just want to give everyone heads up regarding insurance coverage. I spoke to my carrier BC/BS of New Mexico. They do cover lap band for patients with a BMI 35-40 who have co-morbidities, without a huge list of other hoops. That was the good thing I have been very excited because knew I was qualified and just had to wait it out.and go through the steps. I called again today and asked some more questions. What I found out is that even though those are the requirements for the insurance company , my employer has tacked on another more strict condition and you have to have a BMI of 40. No exceptions for co morbidities, or the fact that the plan covers it. I am so upset right now. ( crying of course ) So I either an sol or I would have to gain a minimum of 25 lbs to qualify. So I am basically out the $450 program fee I paid, and the $250 copay for the endoscopy. I was too upset when I spoke to the surgeons office to ask for a partial refund of the program fee. ( they will probobly remind me that it was non-refundable) Anyway just a heads up for those who are borderline, to not take the insurance companies or surgeons word without asking a ton of probing questions, and restating the information back to them, to make sure it is correct.

[Grider 92]

I gained 10 lbs more to keep me at 43BMI and have lost down to 41 BMI and holding.. I am not quiet done with everything, but that's other tests etc. I have heard many had to re-gain weight to apply.. so dont give up the ship! nobody said you need to do surgery on a particular time frame, they cannot hold you to an excat date for surgery.. what are the possibilities? it's alot 25 lbs to gain but ,, When does the new ins. kick in-? any changes? ours is Jan 1, 2012,

I had called and said Ok -I did all this, and now the medical tests are delaying my surgery, will my required process run out of time,? I was told NO,,, so if my medical tests took 3 mo more,,, I still did my needed stuff to be approved --make some more calls- but dont tell ins co you might just eat cake n ice cream for 30 days--

[proshooperLinda 7]

I just want to give everyone heads up regarding insurance coverage. I spoke to my carrier BC/BS of New Mexico. They do cover lap band for patients with a BMI 35-40 who have co-morbidities, without a huge list of other hoops. That was the good thing I have been very excited because knew I was qualified and just had to wait it out.and go through the steps. I called again today and asked some more questions. What I found out is that even though those are the requirements for the insurance company , my employer has tacked on another more strict condition and you have to have a BMI of 40. No exceptions for co morbidities, or the fact that the plan covers it. I am so upset right now. ( crying of course ) So I either an sol or I would have to gain a minimum of 25 lbs to qualify. So I am basically out the $450 program fee I paid, and the $250 copay for the endoscopy. I was too upset when I spoke to the surgeons office to ask for a partial refund of the program fee. ( they will probobly remind me that it was non-refundable) Anyway just a heads up for those who are borderline, to not take the insurance companies or surgeons word without asking a ton of probing questions, and restating the information back to them, to make sure it is correct.

Before you panic - call the doctors office...the program fee may be extended to when you can qualify. The insurance people in the office usually know what they have to do to "work" around the system. You can postpone surgery and at this time of year it would be easy to gain enough weight to qualify...(tongue in cheek)...but the doctor can also challenge their refusal to cover the operation. NEVER accept the decision! I was on the benefits comittee at work and found out you could usually get decisions reversed when challenged! Good luck.... PS - depending on your results from the endoscopy it might not need to be redone at a later time....plus your coverage could change for the better at any time as rarely is a health care contract unchanged year after year!

[abqann 3]

Thank you for your support in this. I am trying to decide if I should complete the nutrition counseling for this month ( last session was scheduled for today) or not. I was so upset yesterday I did not go to work! I was told by the nurse that my employer does not bend on this requirement for a bmi of 40. The thing that upset me the most is that I called and asked about coverage, and the Dr office did the same. Also I am upset that the insurance person at the Dr office either did not know what to ask or just blew it off. She was kind of flippant with me when I spoke to her yesterday, just said oh yes I had another patient that was denied for the same thing recently. I am kind of mad right now, and am thinking did you even think to let me know or just go on my merry way thinking I would be approved? The other plan my employer offers requires a bmi of 40 and 5 years of weight documentation with a bmi of 40 for the entire time. I may look into my husbands coverage. He has United but his open enrollment is in June. So do I keep plugging away or take this as a sign that it was not meant to be? Not sure what to do.

[MelindaH 3]

Thank you for your support in this. I am trying to decide if I should complete the nutrition counseling for this month ( last session was scheduled for today) or not. I was so upset yesterday I did not go to work! I was told by the nurse that my employer does not bend on this requirement for a bmi of 40. The thing that upset me the most is that I called and asked about coverage, and the Dr office did the same. Also I am upset that the insurance person at the Dr office either did not know what to ask or just blew it off. She was kind of flippant with me when I spoke to her yesterday, just said oh yes I had another patient that was denied for the same thing recently. I am kind of mad right now, and am thinking did you even think to let me know or just go on my merry way thinking I would be approved? The other plan my employer offers requires a bmi of 40 and 5 years of weight documentation with a bmi of 40 for the entire time. I may look into my husbands coverage. He has United but his open enrollment is in June. So do I keep plugging away or take this as a sign that it was not meant to be? Not sure what to do.

Personally, I would keep plugging away.....do you have co-morbidities? Hopefully your husband can get coverage for you in June. Another thing that bothers me is that you had to pay a program fee.

Did you go to a Center of Excellence. Not sure where you live, but if you can, use them. They do not charge a program fee. At least the one I am involved with doesn't.

All the best to you, hon. Where there is a will, there is a way.

Keep us posted.

Melinda

[Slim Down Donna 2]

I just want to give everyone heads up regarding insurance coverage. I spoke to my carrier BC/BS of New Mexico. They do cover lap band for patients with a BMI 35-40 who have co-morbidities, without a huge list of other hoops. That was the good thing I have been very excited because knew I was qualified and just had to wait it out.and go through the steps. I called again today and asked some more questions. What I found out is that even though those are the requirements for the insurance company , my employer has tacked on another more strict condition and you have to have a BMI of 40. No exceptions for co morbidities, or the fact that the plan covers it. I am so upset right now. ( crying of course ) So I either an sol or I would have to gain a minimum of 25 lbs to qualify. So I am basically out the $450 program fee I paid, and the $250 copay for the endoscopy. I was too upset when I spoke to the surgeons office to ask for a partial refund of the program fee. ( they will probobly remind me that it was non-refundable) Anyway just a heads up for those who are borderline, to not take the insurance companies or surgeons word without asking a ton of probing questions, and restating the information back to them, to make sure it is correct.

Not to be flippant, but go weigh in with good ankle weights under long pants. Also load your pockets down with coins. Good luck and do not gibe up. Even if it did not work out with current ins. The work will be done to completion for the next ins.

[mynewlife2011 6]

Sorry to hear about that.....

Back in 2009 I was very excited to learn that the insurance company I had covered Lapband, so I went to a seminar and was about to set up an appointment to meet with a surgeon when I discovered my EMPLOYER (Verizon Wireless) did not cover it. Needless to say I was peeved.

Now in 2011 my wife is about to get insurance through her new job. It took alot of digging and calling different people (her HR department, UHC, UMR, etc) but we did verify that both the insurance and company cover Lapband. As far as our requirments my wife was told they would be the UHC requirments, so we have someone in her HR department trying to get us the EXACT information we need. I want to have every peice of info I can get involving requirments before I attend another seminar on the 16th.

In a case like yours I personally think the surgeon/doctor SHOULD refund all or at least 1/2 of what you paid them.

I have UHC also and my employer allows for the surgery HOWEVER i am fighting with UHC right now because they are not wanting to pay for it until Aug 30 of next year because I was already overweight when I got the policy...UHC is pretty easy about the Qualifications...complete history and physical..Bmi of 35-39.9 with co morbidities or over 40 without.I have total choice plus..Like I said they cover it just fine and If i wanna wait till aug it will only cost me my ded which is 250....If I cant get the pre existing condition status lifted then I am just about thinking self pay because I just recenty had a bad bout with my hypertension and I really dont want to wait till aug...Hope it all works out for us all....

[abqann 3]

Thank you all for your responses and support. I did my due dillagence at they beging by checking with the insurance company when I first started the process. My Dr office checked with them to pre qualify me. The part that makes me angry and upset is that I would have expected that the insurance coordinator as a professioal would have known what qustions to ask, as in does the employer have special requirements and what are they. My employer cannot be the only one who does this. When I started the process it never dawned on me thet they would have this requirement, different from the carriers. I am not even sure whyI called and asked more questions that day. I just wanted to make sure everything would be ready to submit in December. I do believe everything happens for a reason and maybe this was not the path I should take for my journey. Good luck to all of you !

[xavier 153]

Keep going...dont give up! I think I needed to gain 38 pounds or self pay and ultimately I decided to self pay. But now that all is said and done I might have tried to gain it...I was scared the lap band wouldnt work and I would just be that much fatter. But now in maintenance maybe it was doable!

The other thing is, plenty of people here on this site have done all kinds of sneaky things to seem to weigh more at the doc's office and I dont think the docs really care...the surgeon just wants to do the procedure so why should he care that you have ankle weights on?

Seems like 15 would be ok to gain (it would have saved me $1,000 per pound!) and then ten in sneaky weight. I know one gal who drank a gallon (almost) of Water and then wore a diaper in case she couldnt hold it! PS: A gallon weighs 8 pounds!

Good luck, life is not fair, but do not give up!!!

[xavier 153]

Oh!Also make sure your height has been accurately measured because depending on your age maybe you have lost some...an inch (many gals have slouched purposely for this!) makes a huge difference!!!

[loretta\ Baconton Georgia 10]

When you get your insurance ask for a copy of your policy. Maintaining a high weight is not necesary. They go by the weight that you were at befor you started your 6 months diet plan. Atleast that is what it says in BC/BS of Illinois manual.

Personally, I would keep plugging away.....do you have co-morbidities? Hopefully your husband can get coverage for you in June. Another thing that bothers me is that you had to pay a program fee.

Did you go to a Center of Excellence. Not sure where you live, but if you can, use them. They do not charge a program fee. At least the one I am involved with doesn't.

All the best to you, hon. Where there is a will, there is a way.

Keep us posted.

Melinda

[Scooterbug 13]

I have UHC also and my employer allows for the surgery HOWEVER i am fighting with UHC right now because they are not wanting to pay for it until Aug 30 of next year because I was already overweight when I got the policy...UHC is pretty easy about the Qualifications...complete history and physical..Bmi of 35-39.9 with co morbidities or over 40 without.I have total choice plus..Like I said they cover it just fine and If i wanna wait till aug it will only cost me my ded which is 250....If I cant get the pre existing condition status lifted then I am just about thinking self pay because I just recenty had a bad bout with my hypertension and I really dont want to wait till aug...Hope it all works out for us all....

Thanks for the reply and heads up. When you got your policy was it during open enrollment?

I am going to school full time for Medical Billing and Coding. This semester we started on our Insurance part of the class. From what I understand (and also clarified with my instructor) during open enrollment an insurance company is not "supposed to" use the pre-existing condition against someone. If you did start your insurance during open enrollment, make sure you fight them tooth and nail.

"Regulations about pre-existing condition exclusions may vary from state to state, but generally speaking the following applies: If you are enrolling in a health plan on an approriate eligibility date (such as open enrollment, taking a new job, becoming newly eligible due to marriage, etc.) pre-existing condition exclusions do not apply"

My wife just signed up during open enrollment...so going by what I have read and researched, pre-exisiting condition should not be a problem. Keeping my fingers crossed.

[loretta\ Baconton Georgia 10]

Preexisting comobidieties will actually help you get the band faster in this case.