Tricare Prime, anyone?

[Tiffykins 673]

I have tricare prime and I'm getting it approved. I have a PCM at an Air Force base who has referred me to a civilian surgeon. He says no prob!

When you get the approval, let us know because I've just had 2 more friends denied after jumping through the 6 month pre-op requirements, the psych eval, the nutrition class and the letter came down last week that ONLY Bypass and the band are approved.

[Tiffykins 673]

This is the most recent 2012 Sleeve Gastrectomy information from TRICARE:

http://www.humana-mi...ull-i1-2012.pdf

It says it does cover the surgery and has conditions on what your BMI needs to be to cover the surgery.

Hope this helps everyone.

Medicare denied covering it just yet, so Tricare isn't either.

So, you are correct, it is STILL a non-approved, non-covered, procedure with Tricare unless performed at an MTF then Tricare really isn't paying the claim as they do to civilian doctors.

[samakar1516 1]

Whoever replied to this original post and said that Tricare does cover the slleeve gastrectomy according to the latest newsletter is incorrect. If you look on page 2 of that newsletter, it tells you what they do not cover, and it is listed on there as not being covered.

But this should apply only if you're not active duty.

If you are active duty, you should just be able to ask your regular clinic doctor for a referral or appointment to the bariatric clinic if your MTF does the procedure.

Make sense?

[Char 7]

Tricare coverage for the VSG will continue to be a hot topic until Tricare approves coverage. I'll share my story again to perhaps make it easier for active and retired military personnel and family members to get a VSG.

I'd like to mention first that current coverage refers to vertical banded/sleeve gastroPLASTY, which is entirely different than vertical (or longitudinal) sleeve gastrECTOMY. The difference is with gastroplasty, they are simply stapling off part of your stomach as opposed to gastrectomy, where the majority of the lower portion of the stomach is removed from your body. Gastroplasty is reversible if necessary. Gastrectomy is not. Once your tummy is gone, it's gone, tossed in the bio-hazard bin and burned. As far as I'm concerned, burn, baby, burn! I love my sleeve.

The reason you can obtain a VSG on base and can't through an outside surgeon is the MTF's Tricare coverage comes from an entirely different pool of funds than the Tricare coverage paid to outside providers. It's a budgeting issue. The MTF's operate on funds granted to the active military hospital system. Insurance coverage through an outside source operates on funds designated solely for insurance coverage via civilian systems. When it comes to reimbursing for services provided, the two systems do not overlap.

OK, so what now?

Step 1.) Get your referral.

It took months to figure out the maze of retired military vs active military insurance, hospitals, referral processes, etc., but once I did, it's not that difficult. The hardest part is getting the doctors to approve the need for bariatric surgery and getting past the pre-surgical psych evaluation. That's step one. So get started on that if you haven't already. Doesn't matter if it's your civilian or military doctor, although I think it's easier to obtain permission from a civilian doctor. Military doctors can be real snooty about weight management through diet and exercise only. Raspberries....

Once you obtain a referral, you will have to get your VSG at a military facility until Tricare approves the procedure. Since it's new, they want to see the long-term statistics compared to other available options now that the VSG is may be on the way to becoming the procedure of choice for both patients and surgeons.

Step 2.) Find an MTF with a surgical bariatric weight-loss program.

Some facilities have had bariatric programs for several years now. Others are just starting to perform bariatric surgery. Ask how many bariatric procedures have been performed at that facility and how many the surgeon doing your surgery has done. Ask about their complication rate and if any fatalities have occured. The only one my surgeon experienced was death by Whopper. One of his patients upon discharge had someone drive her from the hospital straight to Burger King, ordered and ate a Whopper, ripped out her staple line and bled out before getting back to the hospital. Please follow your post-bariatric liquid diet. Be prepared to experience hunger and know you're going to have to tough it out...yes, I'm digressing.

You may have to do a lot of driving at first, but if you play it smart and get them to combine some of your appointments on the same day, you can cut the expense. We combined my EGD with one of my pre-surgical nutrition sessions and my psych eval with my first meeting with the surgeon.

If you are active duty and are traveling outside of your 99 mile treatment zone, you can get reimbursed for travel expenses if your military doctor has approved your surgery. If you are retired military, you're SOL. Start stashing some cash. FYI, obtaining my VSG took 6 or 7 trips to Ft. Gordon.

Step 3.) Contact the Benefits Management office at the base where you want to have your surgery. You will need to send your referral directly to that base's Specialty Services department within the Benefits Management office. The names of the offices will probably be different within the various services. The BM/SS office is the Army version of the on-base Tricare management team. The Specialty Services office has to approve your referral before you can see a surgeon on that base.

Don't bother trying to go through your normal, local Tricare channels once you get your referral. After 5 months and hours of phone calls, talking to people who had no clue as to what I was trying to do, discovering that the different departments within Tricare have no idea what the other departments do, someone finally admitted that Tricare automatically responds with "this MTF is not accepting new patients at this time" if you are trying to get your surgery done at an MTF outside of your 99-mile treatment zone. I spent weeks calling back and forth with the hospital telling me I have no idea why Tricare is saying we're not accepting patients because we are, then calling Tricare and asking them why they're saying the hospital isn't accepting patients. I'm lucky they didn't cause me to stroke out or rip out all my hair.

Another snafu I ran into was my DEERS information was not registered on the Ft. Gordon list of personnel and family members assigned to or being served by the base. I had to contact the I.D. card office and have them register me into the base system. If you are not in that system, the base BM/SS office nor the hospital can access your Tricare eligibility information online. If your information is not accessible on the base internet system, the hospital can't schedule an appointment until they can register you on their online system. This goes for both military and retired personnel and family.

Step 4.) At this time, you can contact the nurse in charge of the MTF's bariatric surgery schedule and make your first appointment. Standard procedure will most likely be attending the next informational seminar at that base. After that, you're off and running.

[gingersnap 11]

@Char:

Your message is the next best thing to an instruction manual! Thanks so much for taking the time to post this information. Very, Very, Very, helpful information!

[lovex5 25]

Step 3.) Contact the Benefits Management office at the base where you want to have your surgery. You will need to send your referral directly to that base's Specialty Services department within the Benefits Management office. The names of the offices will probably be different within the various services. The BM/SS office is the Army version of the on-base Tricare management team. The Specialty Services office has to approve your referral before you can see a surgeon on that base.

This is where i am stuck. I had my pcp submit the referral which Tricare denied due to...yup, mtf being "full" despite them telling me no they aren't full and they are taking new patients. My next step is to hopefully go to patient advocacy on post and see if they can assist at all. I hope Tricare can release a copy of the refferal request because my dr's office is surely tired of me bothering them about this. The first time it was submitted it was done incorrectly with info left off. I tried to get it corrected by 3 different people then finally had to call the office manager to complain. She took care of it right away but I hate bothering them time and time again about this. Especially because most people don't understand the headache that is having this surgery done if you have a *gasp* civilian pcp. I tried to locate this benefits mgmt office here on post but so far no luck. Do you know what other names they may go by?

[Char 7]

The Patient Advocacy office is either where you need to go or can tell you where the Benefits Management office is located. Just call them. I did everything over the phone. Of course it took from September 2010 to February 2011 to get a straight answer and figure out exactly who to call.

Don't have your civilian PCM send referrals through regular channels. Find out where the Benefits Management team is located and find the people who approve specialty services. I was asked by the Benefits Management team to fax my information directly to the Specialty Services office at Ft. Gordon.

If you go through regular civilian channels (the Tricare system the civilian docs enter their referral requests), all you'll get back from Tricare is the MTF isn't taking new patients, which is hogwash. The 1-800# Tricare reps do not know anything about how to get you on base for bariatric surgery they don't cover. Trust me. They don't know. I had to nag my way way up the chain to get someone who knew that their system had an automated response for certain procedural requests and that the auto reject answer from the civilian Tricare system is" the MTF is not accepting new patients." They don't even contact the hospital, it is an automatied, computer-generated response. No humans are involved. You're fighting a machine. Go to the people on base. Patient Advocacy should be able to direct you to the right people if they aren't the ones who process that base's treatment requests.

[Char 7]

My husband and I call them Tri-2-Care reps.

[Tiffykins 673]

Tricare coverage for the VSG will continue to be a hot topic until Tricare approves coverage. I'll share my story again to perhaps make it easier for active and retired military personnel and family members to get a VSG.

I'd like to mention first that current coverage refers to vertical banded/sleeve gastroPLASTY, which is entirely different than vertical (or longitudinal) sleeve gastrECTOMY. The difference is with gastroplasty, they are simply stapling off part of your stomach as opposed to gastrectomy, where the majority of the lower portion of the stomach is removed from your body. Gastroplasty is reversible if necessary. Gastrectomy is not. Once your tummy is gone, it's gone, tossed in the bio-hazard bin and burned. As far as I'm concerned, burn, baby, burn! I love my sleeve.

The reason you can obtain a VSG on base and can't through an outside surgeon is the MTF's Tricare coverage comes from an entirely different pool of funds than the Tricare coverage paid to outside providers. It's a budgeting issue. The MTF's operate on funds granted to the active military hospital system. Insurance coverage through an outside source operates on funds designated solely for insurance coverage via civilian systems. When it comes to reimbursing for services provided, the two systems do not overlap.

OK, so what now?

Step 1.) Get your referral.

It took months to figure out the maze of retired military vs active military insurance, hospitals, referral processes, etc., but once I did, it's not that difficult. The hardest part is getting the doctors to approve the need for bariatric surgery and getting past the pre-surgical psych evaluation. That's step one. So get started on that if you haven't already. Doesn't matter if it's your civilian or military doctor, although I think it's easier to obtain permission from a civilian doctor. Military doctors can be real snooty about weight management through diet and exercise only. Raspberries....

Once you obtain a referral, you will have to get your VSG at a military facility until Tricare approves the procedure. Since it's new, they want to see the long-term statistics compared to other available options now that the VSG is may be on the way to becoming the procedure of choice for both patients and surgeons.

Step 2.) Find an MTF with a surgical bariatric weight-loss program.

Some facilities have had bariatric programs for several years now. Others are just starting to perform bariatric surgery. Ask how many bariatric procedures have been performed at that facility and how many the surgeon doing your surgery has done. Ask about their complication rate and if any fatalities have occured. The only one my surgeon experienced was death by Whopper. One of his patients upon discharge had someone drive her from the hospital straight to Burger King, ordered and ate a Whopper, ripped out her staple line and bled out before getting back to the hospital. Please follow your post-bariatric liquid diet. Be prepared to experience hunger and know you're going to have to tough it out...yes, I'm digressing.

You may have to do a lot of driving at first, but if you play it smart and get them to combine some of your appointments on the same day, you can cut the expense. We combined my EGD with one of my pre-surgical nutrition sessions and my psych eval with my first meeting with the surgeon.

If you are active duty and are traveling outside of your 99 mile treatment zone, you can get reimbursed for travel expenses if your military doctor has approved your surgery. If you are retired military, you're SOL. Start stashing some cash. FYI, obtaining my VSG took 6 or 7 trips to Ft. Gordon.

Step 3.) Contact the Benefits Management office at the base where you want to have your surgery. You will need to send your referral directly to that base's Specialty Services department within the Benefits Management office. The names of the offices will probably be different within the various services. The BM/SS office is the Army version of the on-base Tricare management team. The Specialty Services office has to approve your referral before you can see a surgeon on that base.

Don't bother trying to go through your normal, local Tricare channels once you get your referral. After 5 months and hours of phone calls, talking to people who had no clue as to what I was trying to do, discovering that the different departments within Tricare have no idea what the other departments do, someone finally admitted that Tricare automatically responds with "this MTF is not accepting new patients at this time" if you are trying to get your surgery done at an MTF outside of your 99-mile treatment zone. I spent weeks calling back and forth with the hospital telling me I have no idea why Tricare is saying we're not accepting patients because we are, then calling Tricare and asking them why they're saying the hospital isn't accepting patients. I'm lucky they didn't cause me to stroke out or rip out all my hair.

Another snafu I ran into was my DEERS information was not registered on the Ft. Gordon list of personnel and family members assigned to or being served by the base. I had to contact the I.D. card office and have them register me into the base system. If you are not in that system, the base BM/SS office nor the hospital can access your Tricare eligibility information online. If your information is not accessible on the base internet system, the hospital can't schedule an appointment until they can register you on their online system. This goes for both military and retired personnel and family.

Step 4.) At this time, you can contact the nurse in charge of the MTF's bariatric surgery schedule and make your first appointment. Standard procedure will most likely be attending the next informational seminar at that base. After that, you're off and running.

Just want to quote it for future reference and easy for me to pull. You wrote it all out so eloquently and precise. Thanks for taking the time for those trying to get VSG.

[Char 7]

You're more than welcome. It was such a pain in the tush to get through the Tricare maze, I figured I should share what I discovered so people trying to get a VSG at an MTF can jump through the hoops without the flames I had to endure. I felt quite singed by the time I had my surgery.

It's kind of confusing if you don't understand that Tricare has two components, an on base MTF budget and an off-base civilian budget. Basically the VSG is covered by the on-base MTF budget and not covered by the off-base civilian hospital system budget. Both active duty and retired people have access to both Tricare budgets. Both also have to go through the approval process to aquire a referral from their doctors. Neither can have the procedure done at a civilian hospital, both must go to an MTF, so you're not dealing at all with the off-base Tricare people who only approve services paid through the off-base budget.

A civilian doctor can do the referral for both active duty and civilian family members. I'm not sure if active duty family members have to have their civilian doctor send the referral to a military doctor or not, but after physician approval, both active duty and civilians seeking a VSG should apply directly through the on-base Tricare system, not the off-base system the civilian doctors access through thier Tricare referral/approval website. Just find out the contact information for the on-base Tricare office (Benefits Management), get the specialty services fax number and contact name and have your civilian doctor fax the referral to the specialty services team for approval.

Maybe it will all start making sense to everyone who reads this thread so they know how to work the system and avoid a stress-induced breakdown.

[Kalimomof3 613]

Just want to quote it for future reference and easy for me to pull. You wrote it all out so eloquently and precise. Thanks for taking the time for those trying to get VSG.

I want you all to know that the Bariatric Clinic @ San Antonio Military Medical Center in TX(the one that used to be BAMC) is a SELF REFERRAL CLINIC it prides it self on being the best Baritatric Program in the DOD and they do Sleeves...I know because I am going through their process now. A lot of patients come from out of area..Hopefully the Self Referral will spread to all Bariatric programs at MTFs but in case you want to know more about SAMMC program I will post a link to their page.Hope this helps!

http://www.bamc.amed...gery/bariatric/