PacifiCare Sucks!

[L8BloomR 1]

Hi,

This is a long post, but I need to vent! Does anyone have PacifiCare insurance? I can't believe what they are doing now! I had been so excited to find I could get coverage for LapBanding, as I have an HMO. (I was surprised to find out that PacifiCare PPO doesn't cover the procedure! ) Anyway, I spent my last 2 days happily setting up the appointments and getting my schedule cleared for all the long trips down to the city I would be going to for the surgery, when I got a phone call from the surgeon's office telling me that PacifiCare just implemented a new policy: Every potential Lap Band patient MUST go to a diet center set up by PacifiCare and be monitored FOR SIX MONTHS before they can start the process for banding!! :angry I couldn't believe and tried to fight it because of the seriousness of my health issues, but there are NO exceptions. Has anyone else run into this? I have about 100 pounds to lose, so what if I lose some weight on this diet program....can they deny me the surgery because I no longer have the required amount of pounds to lose? If I don't lose weight, can they deny me because I will look like I am not motivated? I am so sad, I cried at work when I found out. I have SO many health issues, as well as knee/foot issues that keep me from walking. I was so looking forward to a "new" life; I want that so much! Now, if I do this, it will be almost a year before I can start. My DH and I just got ourselves out of debt.... should I put us back in and just pay for this ourselves? Help!! I am so depressed and upset....:cry and I am so glad you all are there.

Karen

[REEIZBOOJE 0]

I have Pacificare Hmo, they covered me 100% I switched to them because they covered the surgery. I first went to my pcp and mentioned it to her, she told me to first try other methods, so I went on the appointments with the dietitician.(I think I only went on 4 or 5 visits, this seemed like a waste of time to me, sitting there listening to someone tell you how you should eat and writing up a menu, As If!) also on that visit I told my

PCp about pre existing problem with a PsuedoTumor which is caused by being overweight, so then I had to start seeing the optometrist and having all these tests done. All they want is a paper trial that you have tried something else and its not working, I also went to see the gynecologist because I was having nonstop bleeding and Iwas already anemic, I was approved for surgery before I started going to see a podiatrist. My advice whatever ails you due to your weight, go to the doctor get referrals, go see the dietician, whatever it takes, because the time has got to pass by anyway. Right? and then just work on losing as much as you can before the surgery.

[L8BloomR 1]

Hi and thanks for the advice! When did you have your banding done? My understanding is that this is a new policy....the 6-months-diet-center thing. It started in July!! I was a day late, a dollar short, apparently. It is so new that neither my PCP or the bariatric surgeon's office caught it until after I had everything set up. And yes, they were going to cover everything, and I already have a "paper-trail" of all my health issues, that is why I thought I could get around the rule. But after spending an hour yesterday with PacifiCare on the phone, I was told "No exceptions" to the new rule. I know, I could just do the diet and try to pass the time until the surgery, but I have a leg with so many issues and I need surgery, but can't until I lose weight. So if I do the monitored diet, I will be putting the leg/knee surgery off for a year! I am at a painful crossroads.... Thanks for your help and I am glad you got in "under the wire"!

Karen

[Pete53 0]

I have Secure Horizons Medicare HMO in Dallas TX and my first appointment is next tuesday. I guess I will find out. It was hell finding someone who would accept Secure Horizons in first place.

I am 6 ft and weigh 302 BMI is 41 using a calculator and I have many of the Medical issues that are supposed to be helped. My wife is a dietician and she gave up trying to help me with diet. I actually need to lose some weight so that I can exercise.

[Pete53 0]

Well since I posted I saw the Lap Band Surgeon he is a contract Doc with my Secure Horizons Medicare HMO and he told me that he would have approval from Insurance in 30 to 60 days. I called Insurance and since he is a contract Doc I don't even have to deal with my Primary Doc.

I asked what it would cost for the Lap Band and they told me 100 bucks.

So what I learned is that if you have an HMO might serve you well to read up on your contract Docs cause there is always more than one way to skin a cat.

And to think I was considering dropping HMO and just going straight Medicare to pay for it.

[L8BloomR 1]

That is great news, Pete! I am really happy for you! When will you be having your surgery? Unfortunately, I have had both the surgeon's office and my PCP try to get around the 6-month-diet rule and my insurance won't budge. The funny thing is that PacifiCare will only pay for the surgery on the HMO plan, not the PPO, so that is not an option for me, either. I will be going in 2 weeks to meet with the surgeon and try to see if there are any more options. But good luck with your process. I am glad you found a way around this the problem! Let us know how it goes...

Karen

[DrewsLou 3]

I have PacifiCare PPO and the wouldn't cover me. Wouldn't even discuss it. I self-paid and was banded in May.

Good luck to you.

[Pete53 0]

L8 and Lou:

Nothing is set in concrete and at first I had no help at all. No suggestions but I interviewed several Lap Band Docs and the one who told me to come in and that handled Secure Horizons HMO is the one I went to see. He told me that it would be no problem and that was that. I had an appointment to get a scope done and soon an appointment for a stress test.

Last night I talked to the CSR at Secure Horizons and asked a lot of questions. He was very patient and looked up the Doc who is doing the stress test and the Hospital and than he told me this. Dr Barker is a contract Doc and I will not even need my Primary Docs ok.

Its seems that my stumbling on Dr Barker is what has helped the most. If he calls me in and says I have to diet for 6 months fine we all know how that will go.

Since my Insurance is tied to Medicare I can still drop out of the HMO and go 20% copay but I am going to ride this pony for awhile. I have contact with the Doc through email so I can get updates but I have decided to follow his orders and get back after stress test on 13th.

I guess he knows what he is doing as the CSR for Secure Horizons said he does a lot for them. By the way he primarily does the regular bypass and told me that I was the patient that they had in mind for LapBand whatever that means.

I love this Board and I see a lot of support and caring but I am going to be as positive as I can be. I spent 15 years getting sorry care from VA cause I thought it was due me and now I wish I had switched to an HMO 13 years ago when I first got Medicare.

I guess if I had a point to make is that if you are having trouble being approved you might call the 800 number and ask for a list of contract bariatric Docs and hit it from another angle?

Good Luck to all

[DrewsLou 3]

Bariatric surgery is specifically excluded from my policy. Damn employer!

[L8BloomR 1]

Don't you find it just amazing that some insurance companies are helpful in getting this surgery for you and others are not, especially since losing weight is supposed to be the cure-all for so many ailments? The really amazing thing I found out about PacifiCare is that their PPO plan will not cover it, only their HMO plan.... now why would that be?? Makes NO sense! I have thought about paying out of pocket for the surgery, but am worried that if I should have complications and need additional surgery, PacifiCare wouldn't cover it because they didn't authorize the original surgery. Have you found that to be true? Thanks for sharing your insurance stories.... makes me feel like I am in good company!

[bandedlady 0]

I have just been recently been banded and I did pay for it myself. Capital One and Wells Fargo do Health Care financing. I went through Capital One. My employer plan thru the insurance company does not cover any bariatric surgury either, no questions. I don't think I will ever be sorry that I finance it though. I should be getting a big break on my taxes next year because of it. If you have healthcare costs greater than 7.5% of your gross adjusted income, you get to take a couple of thousand off your taxes. Just something to consider. Good Luck!

[L8BloomR 1]

Kristina, thanks for the info about financing. I am SOOOO tempted, but am just afraid of any complications (I have other health issues) that won't be covered if I don't have the original surgery through an insurance company's authorization. Have you had any discussion about that? That is good to know about the tax write-off.... more food for thought!! Thanks for posting!

Karen

[FunnyDuddies 6]

I actually looked into the band way back when we had Pacificare...man were those some tough people to work with sometimes.

One thing I heard about getting around the 6 month diet is if you can show that you have already been doing a suppervise diet. Has your doc had you on any kind of diet? Or a nutritionist? I have heard of some people being able to use this history in lieu of their 6 month supervised diet and getting through quicker. HTH!!

[L8BloomR 1]

What a great idea....wish I HAD been following a doctor-supervised diet, but for the first time in my life I have a doctor who is so wonderful and understanding that he has basically just let me alone about my weight for a long time. He was so shocked to hear about the 6-month-diet requirement because he says that it is obvious I have been battling my weight for most of my life, and that if they would just allow him to send them my record of those battles, this would be over. Pacificare won't allow that, unfortunately. But what a great reminder for any potential banders to get their doctor to follow and document their recent diet history. Wish I had known about that!! Thanks for posting!

[FunnyDuddies 6]

well it is obvious that a lot of insurance companies do the 6 month or 1 year supervised diet just to get you to be discouraged an go the self pay route, or just not do it. sadly, that is what a lot of people end up having to do because of more pressing issues like yours.