What Do They Want? Gah!

[amytug 996]

My head is spinning. I haven't much of a clue what my ins company wants from me.

They sent me a list of the criteria I need to meet. Most of it is simple stuff that is self explanatory. This part I still don't get: 6 consecutive months of a supervised diet with your physician.

Now. Does this mean we want you to get weighed every 6 months, period? Does it mean we want you to eat a diet you have been prescribed by your dr? Or do they simply want me to lose weight? Do they want me to prove that I can't lose weight? What percentage of my body weight do they want me to lose!? If I lose a bunch and am under a bmi of 35, are they going to say " hey, this lady can lose weight," and not approve me? Gahhhhh.

No one knows. Face/palm.

I went to my dr to get weighed and have him sign the referral and asked him what he wants me to do to lose and how much I should lose etc. he says " ask your ins company, I usually do an 1800 calorie eating plan.". So I leave and call them immediately and thy say " that is something you would have to discuss with your surgeon..". I call my Bariatric office and they say " ask your insurance company. ". I'm ready to scream. Or take some anti nausea mess from all he spinning in circles I'm doing. Where do I go from here? Gah!! The lady that answered the phone at the Bariatric place, she seems to think that the ins company wants me to lose weight so I no longer qualify for Bariatric surgery because I have no comorbid conditions and my bmi is JUST at 40.7. Yikes. She did transfer me to the nurse, where I got voicemail, and she has yet to call back. In her defense, it was late in The day when I called.

I'm so lost. This phase is so so frustrating. I feel in my heart his will all eventually work out for he better but it's hard to relax not knowing if I need to fill my next 6 mos w Cookies and cake or green smoothies and melons. Kwim? Oh I'm tired already, of his ins stuff. They aren't weeding me out tho. I'm a fighter. Maybe all these calls I'm making to the ins company will look good to them when he surgeon submits the paperwork.

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[joyful noise 101]

I chose to go a nutritionist for 6 meetings, rather than go to my pcp. I was weighed at the meetings and given knowledge of good and bad fats, carbs, etc. I think they ( the ins co ) go by what you weighed at the onset; not what you've lost. We all can lose weight...but keeping it off...

Hence the surgery tool for help losing and keeping it off.

[Bubbaloo10 55]

I think you should lay this at the feet of your bariatric surgeon's insurance person. Most bariatric practices have a person (usually a lady) who is well versed in what it takes to get approved. They talk to insurance companies all the time as part of their job. After all, the doctor's success at getting patients is primarily up to this person. They need your insurance money more than they need you, so let them find out the criteria. Then, if they're worth their pay, they will do everything they can to get you cleared. Don't stress over this...it's just another hoop you have to jump through. Good luck.

[Wheetsin 714]

My head is spinning. I haven't much of a clue what my ins company wants from me.

They sent me a list of the criteria I need to meet. Most of it is simple stuff that is self explanatory. This part I still don't get: 6 consecutive months of a supervised diet with your physician. It (most of the time) means that you need to see a physician regularly, for a 6 month duration, for the sole purpose of him/her supervising a formal weightloss effort. Weighing must be done regularly. I believe the visits must also be coded as visits specifically for weightloss (I don't know the code or actual term). In other words, you cannot (most of the time) gather 6 months' worth of Dr's visits for this and that, where you happened to get weighed, and submit it. Unsupervised programs such as doing your own low carb diet, or Weight Watchers without doctor's visits, generally do not work either. Does that help at all?

Now. Does this mean we want you to get weighed every 6 months, period? I believe the visits are generally monthly. It's not multiple 6 month periods, it's multiple times within a 6 month span. Does it mean we want you to eat a diet you have been prescribed by your dr? Or do they simply want me to lose weight? Dr.will generally prescribe a calorie-specific diet, or refer you to a nutritionist and then follow your progress. Kind of varies from Dr to Dr. Do they want me to prove that I can't lose weight? Not at all. At a fundamental level, what they're wanting are 6 months' worth of premiums to help balance out your risk pool -- if they're going to pay for a $$$ procedure, they want to ensure up front that you're giving them something toward it. What percentage of my body weight do they want me to lose!? Insurance companies generally do not require any particular amount of loss. They just require it be medically supervised. If I lose a bunch and am under a bmi of 35, are they going to say " hey, this lady can lose weight," and not approve me? Gahhhhh. I have heard of this happening. On the flip side, I have also heard of people not losing enough and being denied. What insurance company do you have? For most of the larger companies, this is essentially a formality. Like I said above, it's 6 months' worth of premiums and balance across the coverage group.

No one knows. Face/palm. Both your surgeon's office and insurance company should be able to answer these questions for you. Also, if "loss of X" isn't stated in their requirements, usual there's no requirement. When there are requirements, they're usually well spelled out (such as BMI requirements, comorbidities, etc.)

I went to my dr to get weighed and have him sign the referral and asked him what he wants me to do to lose and how much I should lose etc. he says " ask your ins company, I usually do an 1800 calorie eating plan.". So I leave and call them immediately and thy say " that is something you would have to discuss with your surgeon..". I call my Bariatric office and they say " ask your insurance company. " If your coverage requires "medically supervised diet" it would come from a PCP or equivalent, not your surgeon's office (that I know of) and not your insurance company. The 1800 calorie plan sounds right (see mentioned above that usually it's a PCP-led program of a prescribed calorie count) It's a doctor, and he/she is supervising. The insurance person you talked to probably didn't understand the requirement. They, too, should be able to tell you if having a reduced calorie plan supervised by your PCP is adequate )it really should be). Your surgeon's office, also just through experience if nothing else, should be able to give you an idea but they will not be responsible.. I'm ready to scream. Or take some anti nausea mess from all he spinning in circles I'm doing. Where do I go from here? Gah!! Set up an appt with your doc and see what the 1800 calorie plan is all about. I'd also call insurance and see what follow-up intervals they require to constitute "supervised" -- monthly, bi-monthly, etc. Then -- schedule. The lady that answered the phone at the Bariatric place, she seems to think that the ins company wants me to lose weight so I no longer qualify for Bariatric surgery because I have no comorbid conditions and my bmi is JUST at 40.7. Yikes.This isn't true. People who don't understand how insurance companies work like to villainize them, but an insurance company would never try to make you disqualify yourself from coverage for something. They just expect their criteria to be met. If you're unsure, call your insurance company and ask if you drop below the 40 BMI during pre-op, will you be disqualified, or will approval be based on your starting BMI. She did transfer me to the nurse, where I got voicemail, and she has yet to call back. In her defense, it was late in The day when I called.

I'm so lost. This phase is so so frustrating. I feel in my heart his will all eventually work out for he better but it's hard to relax not knowing if I need to fill my next 6 mos w Cookies and cake or green smoothies and melons. Kwim? Oh I'm tired already, of his ins stuff. They aren't weeding me out tho. I'm a fighter. Maybe all these calls I'm making to the ins company will look good to them when he surgeon submits the paperwork. They won't make a difference. But you will be better informed for having made them, and that's nearly priceless when dealing with this stuff.

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HTH!

[amytug 996]

Oh wheetsin, so super helpful, thank you for holding my hand through this!!!

Actually, when I left he dr office and called the Indurance company (BCBS MI, PPO) i did ask her about dropping below that bmi. That is when she replied that I had to talk Iy surgeon.

Remember when we were kids and wanted so desperately to be a grow up? If only we knew then......

[Wheetsin 714]

BCBS is pretty good about clearing up confusion. It just may take a few calls to get someone who knows head from arse. I have Anthem BCBS CA but I was a revision so my 6 month diet was waived. Never had to deal with that.

Normally your surgeon's office advocates for you, gets your requirements, and can answer questions but they can also misinterpret. I've seen it several times. You might want to take (if you haven't already) a copy of your requirements to your PCP and let them read for themselves what's required. If they haven't worked with a WLS patient in the pre-op stage before, they may truly just have zero clue what's what.

Be diligent, and keep posting any questions you have. There are a few of us around who have good "insider info" on the workings of insurance companies, who will be happy to help as much as we can.

[phatdivabbw 86]

Have you been following a surpervised plan over the past 6 mths? My insurance allowed me to use the nutrtionist visits as my 6myh plan. I do agree the insurance coordinator knows what the insurance company will accept or what to do to submit you paperwork.

[amytug 996]

I just now started went to my dr to be weighed in yesterday for the dfrst time

Phat, ot, but I don't have to get a sleep study done as part of the criteria I have to meet and my pcp didn't bring it up, but do I need to initiate study for my own safety,during surgery? Ive suspected it before and just never went to the study.

Also, why did you get the catheter ting put in? I mean I googled it and know what it's for but why do u get one? I've never heard of that before. Do all surgeons do that?

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[IMSKINNY 160]

Wheetsin, that was super duper helpful info! My paperwork gets submitted after my last visit to my surgeon in June. I am startimg to get a little nervous....

[amytug 996]

Okay

I called the ins co and the Bariatric team both today and got people who knew what they were talking about.

They both said that I cannot lose weight because BCBSMI will be going by my ending weight, not my starting bmi. Lady at the Bariatric place says it's just the silly ins companies hoop and they just want to see who will see it through to the end. So. I really wanted to lose some, but I suppose this is worth staying fat for 6 mos for.

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[Wheetsin 714]

I've heard of people going to extremes -- basically insurance fraud (things like sewing weights inside of their clothes to make themselves heavier). How much can you lose and still make the BMI requirement? Maybe shoot for somewhere in between. That way you aren't sabotaging your approval, but you're also starting on weightloss.

I'm glad you finally got ahold of someone who knew up from down. Just like with anything else, there are good ones & bad ones.

[amytug 996]

Not sure. I have to be 40 and I am 40. Lol. Ins co and the lady at the office both said not to lose. Even my pcp's nurse, who has had rny said that they could just weigh me every month and say that they have me on an 1800 cal diet and write that I can't lose. Lol. Do you think that will sabotage things? Maybe if I only lose 1 lb a month, or have the dr write that I did st least? I am gonna have to search for the bmi calc in a bit. Basically, my dr/ nurse are willing to make it look good for me.

[Wheetsin 714]

BMI calculator

BMR calculator

Your BMR is basal metabolic rate - how many calories you need to do nothing, and not lose weight. To your BMR you add the number of caloies you actually use up in a day through various actvities, exercise, etc. That's the number of calories you need to maintain. Subtract that from your daily caloric intake. If you end up with a positive number, you're eating more calories than you need to maintain. If you end up with a negative, you're eating fewer and will have a defecit (weightloss). You won't equal out, so don't worry about that.

That's a really fundamental equation. All kinds of variables. But what it takes to gain, or not lose, depends on a lot more than your BMI and on a lot more than statistical averages like "2000 calories a day".

[amytug 996]

I know my body well enough, I think, that as long as I cut out soda and sweets towards the end of every month, maybe throw in a green smoothie or 2 them I should lose a lb or 2. I'm really positive that my dr. Will write down whatever I need him to. Lol