Unethical bandsters?

[Wheetsin 714]

Opening this up for discussion, not judgement or criticism.

One of the things I've witnessed here that has always made me raise my eyebrow a bit is people's questions about -- and others' willingness to help -- "beat the system", so to speak. I haven't seen the topic come up in a while, but when I first joined it was fairly common for someone to want advice on how to qualify for the lap-band, even though they don't qualify. And there was a lot of advice given about putting sand in clothes, weights in shoes, forcing down a gallon of Water before being weighed, etc.

Opening this up for discussion - in general - is it ok to "nudge" the system this way? Is there anything wrong with doing it? What's the line between what's "ok" to nudge, and what isn't?

[Carlene 12]

I guess desperate people do desperate things. I'm not convinced that any of those things would increase your weight by more than a couple of pounds, and if that's all you need to qualify, it might be easier/more ethical to just eat a box of Krispy Kremes every day for a week.

[FunnyDuddies 6]

I don't know. That is a very interesting question. Somethings to look at are why these people want the band. If there are people who obviously have weight issues, but they are on the low side of a diet, should they have to gain it back just to have the band put in? My mother worries about this. If she goes on a diet, loses a bunch, but sees it coming back, will she have to gain it all back just toget the band to help control her weight?

In france they are actually starting to put the band in teens who are showing difficulty with managing their weight so that they do not get too big and develope health problems. I think this is a good thing.

Look at people who have gotten to goal, but have a band slip or erode. Many of them get a new band put in even though they are no longer obese. Because it is more of a control mechanism rather than a weight loss mechanism.

I think it is good that some of the Mexico docs are willing to put in a band on someone who is below the 35bmi level. There are a lot of factors that go into our weight. And it is all individual.

But I do have that niggling feeling about people who just want it as a vanity tool. Someone who is 20 pounds overweight wants it to lose those 20. Is it necessary? Prolly not. But who am I to tell them they should or should not get it? I am not paying for it LOL Unless they have state ins or something. HA!

[Alexandra 55]

Unfortunately, our healthcare system invites this sort of skullduggery. Lines are drawn and treatment is given or not given based on these lines, rather than on the judgement of medical professionals.

As a health insurance broker I encounter this sort of thing all.the.time. It's never OK in my book. If there is a legitimate medical reason for a treatment and a medical professional can make the case, carriers should pay in accordance with the contract. If the decision isn't what we want, there are avenues for appeal.

There's never an excuse for lying or cheating, and it's completely unwise as well--if fraud is discovered, the least of what can happen is being held responsible for paying back the paid claims.

[warmmorningsun 1]

Look at people who have gotten to goal, but have a band slip or erode. Many of them get a new band put in even though they are no longer obese. Because it is more of a control mechanism rather than a weight loss mechanism.

I think it is good that some of the Mexico docs are willing to put in a band on someone who is below the 35bmi level. There are a lot of factors that go into our weight. And it is all individual.

You bring up a good point FunnyDuddies...currently the band is approved for use as a tool for treatment, rather than a tool for prevention...a thought to ponder another time I guess

My belief is that there are those of us who are desparate for intervention with our weight problems and desparate to get what seems to be a successful intervention and treatment for that problem. I don't agree with 'gaming' the system so to speak, but more on a personal moral ground. It's lying and I think lying is wrong. I think on the other hand though that the insurance companies are not in touch with preventative medicine and if they were to address what causes obesity, they wouldn't have to treat it as much...kwim?

[Maya 0]

this is a test for my ticker.

[Maya 0]

Cool! I did it.

[Teresita 0]

Maya you did it, you did YEAHHHHHH I've seen you playing with that thing forever and everywhere. YEAHHHHHHH WHOOOHOOOO:clap2: :clap2: :clap2: :clap2:

[Sunta 5]

In my opinion, the health care system and insurance companies in particular do waaay more lying and cheating and unethical practices than any patient could ever do. If someone cheats me, do I feel fine taking what is rightfully mine? Yes, I do. If someone feels that they are being cheated out of a surgery they really need because the insurance company just doesn't want to foot the bill, then they have every right to obtain that surgery for themselves. We pay good money to be insured, and too many times when it comes down to it, insurance companies try to wriggle out of paying for things that they rightfully should be paying for. Let's face it, the reason why the weight limit is 100 pounds overweight is because it would be "too expensive" (meaning maybe the fat cats who sit at the top of the corporate ladder might earn less) for insurance companies to foot the bill for everyone. Many corporations have lots and lots of millionaires benefitting by shirking their real responsibilities which is to pay for people's health care. If my neighbor steals my money and keeps it in house and the police won't help me, will I break into his house to get it back, even though breaking in to someone's house is wrong? You bet your booty I will!!!

[Poodles 0]

Insurance fraud is never good. It only hurts those that truly need the surgery. True insurance companies try to get out of everything, but two wrongs do not make a right.

[NewSho 20]

Opening this up for discussion, not judgement or criticism.

Yes, honestly it does seem judgmental - you've got your band and congratulations. So ruminating on how others get theirs does seem a teensy bit critical. I don't endorse cheating any established benefit system - but then, I hardly call the American health care beneficial in any way.

I have no idea whether you chose to self-pay for your LapBand or if you were blessed to have insurance cover it. But if you did utilize insurance , with your start weight perhaps qualifying for the band wasn't so much of an issue for you. However for many chronically obese people, getting approved is a huge ordeal and a painfully long process. I see people all the time who are 95# overweight - and have a proven medical need. For insurance purposes, some need to be 100# overweight. It doesn't make me lose an ounce of sleep to tell them to slump down a teeny bit when being measured for height (1/2 inch makes huge difference with your BMI) or even to wear an extra layer of clothes while they are being weighed.

<SNIP>One of the things I've witnessed here that has always made me raise my eyebrow a bit is people's questions about -- and others' willingness to help -- "beat the system", so to speak.

I guess it would seem like that. But it's a $15000+ or more operation that is covered under most so-called civilized countries' national health care system. Although we in the US live in a fabulous country we are still a bit behind the curve in the sense of bariatric treatment and coverage. As we can see, the consequences have been detrimental -we're the fattest country in the world.

Opening this up for discussion - in general - is it ok to "nudge" the system this way? Is there anything wrong with doing it? What's the line between what's "ok" to nudge, and what isn't?

I don't know what a nudge is - but if someone is that close to qualifying, maybe a nudge isn't such a moral dilemma. But why should we all have such a burden for qualifying. I've had friends in the UK, Canada, and Australia who (although they may wait a bit longer in some cases) get their LapBand surgery covered fully - and they most certainly don't have the burden of having to be 100# overweight to qualify. So if you call our Private managed health care industry - "the system" - then I guess there are those who try hard to beat it. Sad that people have to gamble with their health, but sometimes trying to qualify for lifesaving surgery is like spinning a roulette wheel.

I have no problem with those who try anything within reason to help themselves fight the cycle of obesity. It's probably easy as a banded person to speculate on this, but I know how desperate some people when Banding (or other Weight Loss Surgery) seems like their only hope and maybe we shouldn't judge them.

Happy Band (And Life) Journeys To All...

[Alexandra 55]

Talking about nudging the system is a bit specious. It is never a matter of 5 lbs or 1 BMI point that keeps medical necessity from being established. People just don't get declined for this sort of reason if they truly need the surgery.

I mean, if someone has a BMI of 36 and is otherwise perfectly healthy, then no, surgery is NOT medically necessary. If someone's BMI is 38 or 39, they probably DO have some accompanying co-morbidities that would "nudge" the case into qualifying territory. Bottom line: The surgery must be medically necessary for a carrier to cover it. Between the patient and the doctor this determination can be made. Fooling a doctor or lying to the carrier is NOT the way to do it. Being honest with ourselves and our doctors about our health is the very first step in the process, and the medical necessity will be provable if it's there.

Believe me, I'm not one to defend insurance carriers. But they must follow medical guidelines and draw lines somewhere. The system requires rationing, which is true in countries with universal health care as well.

[cashley 0]

I admit I did it... but I was also self-pay.

The surgeon I went to see first wouldn't even consider doing the surgery (self pay or not) if you weren't 40 BMI or 35 with co-mortalities. He wouldn't even consider high cholesterol or high trygliserides or an immediate family history of diabetes and heart disease. My insurance had an exclusion so it didn't matter what my BMI was they weren't paying for it.

I was desperate because I had struggled for so many years and all the diets and exercise and hard work just got me about 30 pounds more each year. I wanted and needed to stop the weight gain... for my health.

I went to another doctor and he also said the same about the 40 or 35 BMI so I added clothes and rocks and heavy shoes... I was 5 pounds shy of the 40 BMI they needed.

I later found out that my new doctor was way nicer and would have done it without the deception. He made exceptions for self-pay that the other center wouldn’t. I asked them but didn’t ask again because they told me it was the law. (it was a law I was willing to break – kind of like speeding)

I'd do it again in a minute. I couldn't take another day of failing at diets, which really just felt like failing.

It was a daily struggle not to let my weight balloon 100's of pounds out of control.

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Since I was self-pay I don’t feel too bad about it.

[cashley 0]

Talking about nudging the system is a bit specious. It is never a matter of 5 lbs or 1 BMI point that keeps medical necessity from being established. People just don't get declined for this sort of reason if they truly need the surgery.

I mean, if someone has a BMI of 36 and is otherwise perfectly healthy, then no, surgery is NOT medically necessary. If someone's BMI is 38 or 39, they probably DO have some accompanying co-morbidities that would "nudge" the case into qualifying territory. Bottom line: The surgery must be medically necessary for a carrier to cover it. Between the patient and the doctor this determination can be made. Fooling a doctor or lying to the carrier is NOT the way to do it. Being honest with ourselves and our doctors about our health is the very first step in the process, and the medical necessity will be provable if it's there.

Believe me, I'm not one to defend insurance carriers. But they must follow medical guidelines and draw lines somewhere. The system requires rationing, which is true in countries with universal health care as well.

I know you work in the industry but the first doctor I saw said "Absolutly not for a BMI of 39... he said "Go and gain the weight and come back"

I also thought he was a jerk and that's why he didn't do my surgery.

[nursekathy2u 0]

I don't endorse cheating any established benefit system - but then, I hardly call the American health care beneficial in any way

.

WHAT????????????????????????? American healthcare is not beneficial in ANY WAY????? I have wasted my life!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Although we in the US live in a fabulous country we are still a bit behind the curve in the sense of bariatric treatment and coverage. As we can see, the consequences have been detrimental -we're the fattest country in the world.

WHAT?????????????????? We are the fattest country in the world because we are behind the times in bariatric treatment???? You mean it's not our diets, sedentary lifestyles, genetics, etc??? Its all the fault of the insurance companies??????????????? We should all sue them!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

So if you call our Private managed health care industry - "the system" - then I guess there are those who try hard to beat it. Sad that people have to gamble with their health, but sometimes trying to qualify for lifesaving surgery is like spinning a roulette wheel.

I'm pretty sure I was gambling with my health everytime I swallowed a quarter pounder with cheese, French fries, and coke.. Make that super-sized please!! Come on!!!! Can't we take a little responsibility for the health problem we created for ourselves???? No Insurance company ever crammed food down my throat nor did the weight magically appear without me looking!!!!! Let's get real here!!!

Kathy