North of 78

[Alexandra 55]

Hey there Jersey gang!

I'm a patient of Dr. Alexander Abkin and will be operated on at Morristown Memorial hospital at the end of this month (providence willing). I'd love to connect with other NJ people from north of the border.

[Mahoney 1]

Hey Alexandra,

I'm in Morris county myself (Long Valley). I'm glad to hear that your surgery went well. I have an appointment with Dr. Trivedi (Hackensack) a week from tomorrow. BTW - Thanks for all of your great posts!

See ya,

Bob

[Alexandra 55]

Hey Bob, nice to meet you! I've heard great things about the Hackensack practice. Are you being covered by insurance? I've heard there's some coming and going with regard to the medical networks. I hope you don't run into a problem!

[Mahoney 1]

Am I being covered?? To be determined It is not a network plan so I'm free to go to anyone I want. I've called my insurance 4 times to check coverage and twice I got the rep to read off the requirements and they said that 40 bmi (or 35 - 39 with serious comordalities) and letter stating medical necessity. We'll see...

[Alexandra 55]

Who is your carrier? I can probably tell you if they're band-friendly or not (but you probably already know)...

[Mahoney 1]

I have a plan that I'm starting to realize is a little unusual these days. It is a self-funded plan by the company I work for (although there is a 3rd party claims administrator). I did a little more digging around today and weight loss surgery is listed in the coverage of benefits section for BMI of 40+, so I'm starting to feel pretty good about things.

[Mahoney 1]

No Cigar Alexandra - denied because of it being (wrongly) considered experimental. I knew it was coming as I researched it more and more. I was initially optimistic because I work for one of the best companies around (IMHO) that covers everything (massage therapy, acupuncture, day care, weight loss surgery), but unfortunately the darn plan administrator (Amerihealth Administrators) fully interprets the WLS coverage clause. I would have gotten approved for the RNY in a second (and I'll resist going into why that is a joke). I'm not upset - I'm just moving on. The appeal process doesn't look too promising because my company's plan is self-funded and I evidently wouldn't get in front of an external arbitrator or any of my company representatives. The insurance companies will catch up, and the surgeons at these seminars will modify their "gold standard" speeches as their gold providers modify their coverages.

In the meantime, off to Dr. Kuri I head (Oct. 30) as a self-pay. I'm I quite comfortable with this decision. At some level I feel slightly guilty for not fighting harder for the cause, but I'm already deflated with these clowns.

My focus now is in trying to learn 30 or so Spanish words.

Dolor = Pain

Adios,

Bob

[Alexandra 55]

Oh, Bob, I'm so sorry. Amerihealth is definitely the worst carrier in NJ with regard to the band. I think you're right, and that they will come around, but I don't blame you one tiny bit for not wanting to wait. If you had a small-group plan your chances of winning on external review would be good, but with a self-funded plan your employers can stipulate what they like and no one can tell them different.

Best of luck to you in Mexico, Bob! What's Halloween like south of the border?

[Mahoney 1]

Hey Alexandra,

I have some potentially good news. I found out that my company is dumping Amerihealth and I'll have a new plan effective January 1. I bugged the plan administrator at my company enough to tell me which company it would be and she did, but she made me swear that I not mention it as all of the contracts haven't been signed just yet. They are a small plan administrator, but she verified for me that they don't consider the lap-band experimental/ investigational and that they cover it. I've been optimistic before , but I found 2 people on www.obesityhelp.com that said the new company covered the band. I don't know what they'll require, but I'm going to hold off on the self-pay surgery for now and try again in January.

BTW - since I now have some extra time, I think I'm going to attend the Abkin/ Bertha seminar next week to see if I like them. Do you have any comments on any differences between the 2 doctors?

See ya,

Bob

[Alexandra 55]

What great news for you, Bob! An extra $10K or so in your pocket sure could come in handy, hey?

I haven't actually met Dr. Bertha. I attended the seminar last summer and just called the office to make an appointment with whomever was more available. Dr. Abkin had the first open appointment. They were both at the seminar but it's not the sort of meeting where you have a chance to chat. (Can you say, auditorium filled with 500 people?)

The paperwork they hand out is blessedly clear. I had no problems at all getting my pre-op testing out of the way. And if your carrier is band-friendly I'm sure the office staff are extremely efficient at all of those issues. One of them even called me today to remind me that I needed a new referral! (That's pretty much unheard-of for a busy specialist's office to do. It's the patient's lookout, not theirs.)

Frankly, my exposure to the surgeon has been minimal. I think I saw him more on surgery day than all other times combined, and that was a total of about 10 minutes. He's a lovely guy, very nice and encouraging, but I have much more contact with his staff. And as far as I know, the doctors share the staff.

You won't get much out of the seminar, unless they've changed it significantly since I went. But you must attend to pick up the paperwork. However, so the evening won't be a total loss, check out this great Afghan restaurant over near the courthouse. I highly recommend the eggplant appetizer!

[Mahoney 1]

Hey Alexandra,

Thanks for the restaurant suggestion. If I was able to arrange baby-sitting with the grandparents, I was planning on trying that restaurant with my wife. No luck, but I did attend the seminar. It was similar to the Schmidt/ Trivedi seminar (the Hackensack docs) - probably a little more crowded and slightly more salesy. One of the things I liked about Dr. Trivedi is that he really wanted to talk about any negatives with the surgery. Otherwise, it was the same type of thing. There is one big difference between Hackensack and Morristown after the seminar. The Morristown center does a lot more/ requires a lot more before surgery. For Hackensack, you attend the seminar, you meet the surgeon for 10 minutes, you get your date, you show up. As you know, Morristown requires the seminar, psych exam, nutritionist, extensive blood work, meet the surgeon, get your date. I had the psych exam and nutritionist today, and although I was kind of dreading it beforehand, it was pretty good. I think these extra precautions demonstrate a more thorough approach (or more paranoia for a lawsuit :cool: ). I won't make up my mind until I meet Dr. Abkin around Thanksgiving, but I was impressed today.

See ya!

Bob

[Graceful One 4]

Just an FYI. If you get denied due to experimental/investigational Inamed is now doing the appeal with your doctors office. Whom ever you decide to go with you may want to ask if they know about this.

[Christine 0]

Hi Alexandra! I am considering having the surgery. I am attending the seminar at Somerset Medical Center and the next night at Morristown. How long was it after you attended the seminar? Hopefully they will be able to tell you if your insurance covers the surgery. I live in Middlesex but work in Morristown. :

[Alexandra 55]

Hi Christine!

I found out even before attending the Morristown seminar that my insurance would not cover banding, but I went ahead anyway. After all was said and done it took almost a year from my seminar until surgery, but obviously it wouldn't have taken anywhere near as long had I not had the insurance problems I had.

You should be able to get a quick, straight answer from the doctor's office about whether your insurance will cover the band. It's not something that comes up at the seminar--it can't with something like 500 people in attendance--but certainly at your first appointment you'll get the info you need.

Dr. Abkin & Bertha's office is incredibly busy, but if you're having band surgery the wait isn't as long. There are fewer of us and the surgery is done outpatient there, so scheduling it is not a big deal. Once I had my insurance approval my surgery date was 6 weeks later.

Good luck!!

[Christine 0]

Alexandra

I am new at this whole chat room thing. I am not sure if my prev post went in. Thank you for all the information.

How are you feeling/doing 3+ months after surgery?