Just Decided To Have The Sleeve Done...where The Heck Do I Go From Here? Help!

[nadoue 158]

Again Kendra, if you are lucky like me lol, you won't have the hassle to deal with. I started my process around my bday in July and had my surgery sept 14. I didn't have to contact my insurance, no requirement, no preop diet, I was breezing thru the whole thing. I only got my surgery 2 months later just because I wanted my black surgeon and he was all book. I don't post much just becoz I can't relate to a lot of thing but I can tell you this: it is the best thing you can do for yourself

[former_vbg 198]

You didn't ask about this, but it will likely be next on your list regardless of whether you go the insurance route or self-pay, but RESEARCH YOUR DOCTOR. Ask the tough questions, don't be afraid to do so- it is YOUR LIFE. Ask what their complication rate is, look up on the State Medical boards to see what/ if any complaints have been filed against them. Google their name, see what comes up. None of that is full proof that you have a good Dr., so when possible try to find and talk to past actual patients whether its at a support group or online.

Also, understand the details of the surgery- not just that your stomach is being cut out, but find out what size bougie your Dr. uses, and using your research decide if that is the size you want. My surgeon used a size 30 bougie. That is the tool they use to size your new stomach. The actual physical size differences between a 30 and a 40 a fairly nominal, HOWEVER, there are some schools of thought that when you start out w/a slightly larger cut stomach, that the stretching that eventually does occur is moreso than w/a smaller bougie. I'm not sure there is a definitive answer on that, but it was something that was important to me. Some surgeons say they don't want to go smaller than "X" size bougie because they think it increases the chances for complications. Like some surgeons think it can create the hour glass syndrome in your stomach which would be like taking a balloon and squeezing it in the middle and preventing anything getting through the middle. A lot of that is technique. Do they sew over the bougie, do they sew outsize the bougie? Do they use staples? Will you have drainage tubes? Much of this is unique to the surgeon.

The more you read and read and read, and do your research, you will find that while there are many similarities across the board, the individual technique by each surgeon is often slightly different. I spent 3 solid months reading and researching the different Weight Loss surgeries before I started the insurance process. Fortunately, I didn't have to do the supervised diet and only had to start liquids 12 hrs before surgery.

And, of course, we here will all answer whatever questions we can to help you along the way! Good luck!!

HOLY CRAP!!! Thanks to everyone who read and put in their two cents!! All this info is awesome, and please... KEEP IT COMING!! My next step, reread every post, write questions and call my insurance co back.. Ha, I pity the person who takes that call (:

THANK YOU, THANK YOU, THANK YOU!!!!!!!!!

[kmoore 97]

Insurance vs self pay is, to me, a no brainer. If you already know your insurance covers this particular wls, then the out of pocket cost should be somewhere between $1500.00 and $3000.00, depending on surgeon, hospital and physical location in this country. Self pay, $12,000-15,000. Although I would have liked to not have had to do the 6 month insurance required medical management, and been able to get the surgery done exactly when I wanted it done, those 6 months gave SO much time to get myself mentally prepared for the entire lifestyle change we all must make post surgery. I have also spread out the purchases of things I know I will want...small scale to carry in my purse to weigh foods when I am not home with my kitchen scale, a kick butt blender, several wls cookbooks, certain kitchen utensils I didn't have but will need...and TONS of research in reading here too I've also tried several recipes I have found to see if I like them enough to try for post op

Every person is different, and each journey is different. Each person needs to do what is best for them.

On a side note, doctor offices have to charge quite a bit more for insurance pay patients, otherwise no doctor could afford to practice. It's amazing how little an insurance payment is to the doctor. Aside from paying employees, there is that pesky malpractice insurance they have to pay, hospital fees if they work through the hospital, and so on...

Self pay is ALL for the doctor! So, while as self pay, the doctor receives $13,000.00 (all for them), they have to charge 40-50% more for insurance pay just to make $13,000.00 Just a little food for thought

[former_vbg 198]

I wasn't a self-pay, but it was my understanding that the all inclusive fee typically ALSO accounts for what the Dr. has to pay to rent the surgical room and the 1 or 2 nights you stay in the hospital. If not, then I would think that would be a separate fee because the hospital has to get something (anisthesiologist, nursing staff, meds, etc).... Where they pay the hospital out of that one time fee... Am I wrong?

Insurance vs self pay is, to me, a no brainer. If you already know your insurance covers this particular wls, then the out of pocket cost should be somewhere between $1500.00 and $3000.00, depending on surgeon, hospital and physical location in this country. Self pay, $12,000-15,000. Although I would have liked to not have had to do the 6 month insurance required medical management, and been able to get the surgery done exactly when I wanted it done, those 6 months gave SO much time to get myself mentally prepared for the entire lifestyle change we all must make post surgery. I have also spread out the purchases of things I know I will want...small scale to carry in my purse to weigh foods when I am not home with my kitchen scale, a kick butt blender, several wls cookbooks, certain kitchen utensils I didn't have but will need...and TONS of research in reading here too I've also tried several recipes I have found to see if I like them enough to try for post op

Every person is different, and each journey is different. Each person needs to do what is best for them.

On a side note, doctor offices have to charge quite a bit more for insurance pay patients, otherwise no doctor could afford to practice. It's amazing how little an insurance payment is to the doctor. Aside from paying employees, there is that pesky malpractice insurance they have to pay, hospital fees if they work through the hospital, and so on...

Self pay is ALL for the doctor! So, while as self pay, the doctor receives $13,000.00 (all for them), they have to charge 40-50% more for insurance pay just to make $13,000.00 Just a little food for thought

[kmoore 97]

Normally the hospital bills separately...however, if the doc routinely uses the OR's, I'm sure they could contract with the hospital to pay them certain fees out of what they are paid. I work at a family practice, so we don't deal with the hospital end, but I have seen insurance payments...they do gouge doctors a bit. Money makes the world go 'round, right lol

[Wheetsin 714]

Yes. The nurses, anesthesiologists, and hospitalization are not "free" to the surgeon just because it's a self-pay patient. There is a surgeon's fee built into the self-pay rate. A typical surgeon's fee on a quick procedure like this is probably going to be $3k - $5k. That's their salary, so to speak, for the time they spent doing the procedure. E.g. my surgeon's $13K fee covers all pre-op stuff, the information class, etc. The surgery itself, 1 night in the hospital, and a year of post-op visits (only 3 of them are required). Everyone else involved will have to be paid out of the $13k he receives minus his own fee.

I wasn't a self-pay, but it was my understanding that the all inclusive fee typically ALSO accounts for what the Dr. has to pay to rent the surgical room and the 1 or 2 nights you stay in the hospital. If not, then I would think that would be a separate fee because the hospital has to get something (anisthesiologist, nursing staff, meds, etc).... Where they pay the hospital out of that one time fee... Am I wrong?

[Wheetsin 714]

^ a friend of mine is a surgeon who contracts with 4 different hospitals. We've talked about it before and this is the gist of how it works. Per her, and since she's still in practice I assume she knows.

[milkD 37]

Hello!

Some notes about insurance as I am lucky enough to have a husband who's worked as an insurance specialist.

Not only should the doctor you find be in-network but also make sure the hospital and anesthesiologist are covered. If they are in-network then your insurance (as you stated) will cover 80% of it. The first doctor I found was in-network, however the hospital was not so it wasn't an option. Your insurance should also have something called a maximum out-of-pocket. This means there is a maximum amount that you have to pay each calendar year for medical services. This amount on average will be $1,500-$5,000. If yours is $2,500 for example... EVEN if your surgery costs $100,000, 80% would be $20,000 left for you, you would still only pay a maximum of $2,500. I doubt you couldn't finance this cost into monthly payments either. I'm still paying off mine from a year and a half ago for having a baby!

So really there should be no concern abou the actual cost of the surgery as long as the doctor, hospital and anesthesiologist are covered. Please also note that there will be additional testing you'll have to do. Most of this should be covered as well. However my insurance didn't cover the psychological evaluation I had to have. If you're in the same boat you can always find a cheaper psychologist.

It took me about 6 months from the time I initially called to make my first appointment to my surgery date in the end of July. Two of these months were just waiting for the first appointment as my doctor is busy so yours may be faster.

[kmoore 97]

Good points, milkD. I had to see an exercise physiologist too that I paid out of pocket...wasn't even billed to insurance, as that is a non covered expense. However, with 6 months medical management, by the time my surgery date arrives, sometime in the next 2 months, I will be within $300 of meeting my out of pocket maximum of $2500

[kcarroll 4]

Milkd- thank you so much! that was very helpful!! I have a stupid question.. When I called my insurance and asked if wls is covered in my plan, they yes.. 80% after a 2000 deductible. My question- "out-of-pocket" isnt the same as deductible, right?? so, i'd have to pay a deductible, and then the put-of pocket?

Hello!

Some notes about insurance as I am lucky enough to have a husband who's worked as an insurance specialist.

Not only should the doctor you find be in-network but also make sure the hospital and anesthesiologist are covered. If they are in-network then your insurance (as you stated) will cover 80% of it. The first doctor I found was in-network, however the hospital was not so it wasn't an option. Your insurance should also have something called a maximum out-of-pocket. This means there is a maximum amount that you have to pay each calendar year for medical services. This amount on average will be $1,500-$5,000. If yours is $2,500 for example... EVEN if your surgery costs $100,000, 80% would be $20,000 left for you, you would still only pay a maximum of $2,500. I doubt you couldn't finance this cost into monthly payments either. I'm still paying off mine from a year and a half ago for having a baby!

So really there should be no concern abou the actual cost of the surgery as long as the doctor, hospital and anesthesiologist are covered. Please also note that there will be additional testing you'll have to do. Most of this should be covered as well. However my insurance didn't cover the psychological evaluation I had to have. If you're in the same boat you can always find a cheaper psychologist.

It took me about 6 months from the time I initially called to make my first appointment to my surgery date in the end of July. Two of these months were just waiting for the first appointment as my doctor is busy so yours may be faster.

[fatiniowa 10]

As long as you are asking insurance company questions. 1. Do i need to have suervised diet first? 2. Does this need to be a center of excellence? 3. Is the 80% you cover on total or do i need t pay 100% until deductable is satisfied? (I have to pay 100% until my 4500 deductable is satisfied then they pay 90% out of pocket may for me to pay is 7,500) 4. Is everyone covered or do I need a weight related health condition as well.

I am impulsive and it is driving me bonkers. First I had to do psyc eval (3 weeks to get appt) then follow up visit for result, (2 and half weeks more wieght. Have to use center of excellence (they require attending seminar, initial visit and atending 1 of the monthly office sponsered support groups) then the insurance whats to discuss results of psyc exam and is being tough to reach to schedule this. and then the doc office will submit for approval a couple more week wait. OMG, I think the goal is for you to give up so they don't have to pay the claim. And my doctor office said people tha work at my employers helth plan (united health while patentian out of pocket is high is easy to get approved. So just be prepared that it will prolly be a hassle and go to Mexico

[fatiniowa 10]

As long as you are asking insurance company questions. 1. Do i need to have suervised diet first? 2. Does this need to be a Center of Excellence? 3. Is the 80% you cover on total or do I need to pay 100% until deductable is satisfied? (I have to pay 100% until my 4500 deductable is satisfied, then they pay 90%. out of pocket max for me to pay is 7,500) 4. Is everyone covered or do I need a weight related health condition as well?

I am impulsive and it is driving me bonkers. First I had to do psyc eval (3 weeks to get appt) then follow up visit for result, (2 and half weeks more wait. Have to use center of excellence (they require attending seminar, initial visit and atending 1 of the monthly office sponsered support groups) then the insurance wants to discuss results of psyc exam and is being tough to reach to schedule this. and then the doc office will submit for approval- a couple more week wait. OMG, I think the goal is for you to give up so they don't have to pay the claim. And my doctor office said people that work at my employers health plan (united health, while patient out of pocket is high, is easy to get approved. So just be prepared that it will prolly be a hassle and go to Mexico

[BeatrizS1974<3 sleeve 94]

First things first. You may have decided last night that you want surgery but what you have not mentioned is what your bmi is. Do you qualify for weight loss surgery? Do you have co-morbilities? make sure you call your insurance company monday and speak to a live person and ask them to tell you what your requirements are. Also ask them to tell you who the In-Network surgeons are. You don't want to get stuck in the end. This is how i started my process. Good Luck to you.

[milkD 37]

Milkd- thank you so much! that was very helpful!! I have a stupid question.. When I called my insurance and asked if wls is covered in my plan, they yes.. 80% after a 2000 deductible. My question- "out-of-pocket" isnt the same as deductible, right?? so, i'd have to pay a deductible, and then the put-of pocket?

The easist way to break it down is you can think of surgeries like this has having three phases.

1) Deductible phase - this is where you are responsible for 100% of the allowed amount charges approved by the insurance company.

2) Co-insurance phase - this is where the insurance company helps to foot some of the bill in your case 80% of it. Most insurance companies have a co-insurance cap and after that's met...

3) Out-of-Pocket Max Phase - this is where you have satisifyed your out of pocket maximum which consists of your deductible cap and your co-insurance cap combined. Once this is achieved your insurance will begin to process at 100% of the allowed amount for the remainder of your benefit year.

So what you'll want to do is when you speak to your insurance company make sure they clarify co-insurance maximum vs. their out of pocket maximum (even insurance carriers often get this confused in their verbage when quoting benefits).

Here's a basic scenario to explain. Let's say you go and have a surgery and all your bills combined comes out to $22,000.00

You're benefits for insurance include a $2000.00 deductible, a co-insurance of 80/20% with a co-insurance maximum of $2000.00 - that means your out of pocket maximum would be $4000.00.

So 22,000.00 minus the $2000.00 deductible leaves us with $20,000.00

20% (your responsibility of the co-insurance) leaves you oweing $4,000.00 of the $20,000.00 - BUT because we have a $2,000.00 co-insurance maximum you only pay that $2,000.00 and the insurance picks up the other $2,000.00 that would of been part of your 20%.

So your out-of-pocket maximum has been met totalling $4,000.00 of the $22,000.00 bill - even if that bill was 40,000.00 you'd still only pay the $4,000.00 for in-network services rendered.

Sorry for the long explination - it just really helps I think to understand how it all works at the insurance company (they definatly don't make it easy to understand up front lol). I know I wouldn't understand it if it wasn't for my loving, awesome, supportive husband who's super cool.

[former_vbg 198]

Great job in your explanation. The only other thing for her just to be aware of- not that she should delay in the insurance process, but with July around the corner, if she is required to do the 6 mth supervised diet, she may want to do what she can to incur most of her costs in 2013 so she can avoid paying out lots of $ towards her deductible and co-insurance in 2012 and then turn around w/her surgery and get hit again in 2013.

Finding out what her insurance requirements are will determine whether this will likely be an issue or not.

The easist way to break it down is you can think of surgeries like this has having three phases.

1) Deductible phase - this is where you are responsible for 100% of the allowed amount charges approved by the insurance company.

2) Co-insurance phase - this is where the insurance company helps to foot some of the bill in your case 80% of it. Most insurance companies have a co-insurance cap and after that's met...

3) Out-of-Pocket Max Phase - this is where you have satisifyed your out of pocket maximum which consists of your deductible cap and your co-insurance cap combined. Once this is achieved your insurance will begin to process at 100% of the allowed amount for the remainder of your benefit year.

So what you'll want to do is when you speak to your insurance company make sure they clarify co-insurance maximum vs. their out of pocket maximum (even insurance carriers often get this confused in their verbage when quoting benefits).

Here's a basic scenario to explain. Let's say you go and have a surgery and all your bills combined comes out to $22,000.00

You're benefits for insurance include a $2000.00 deductible, a co-insurance of 80/20% with a co-insurance maximum of $2000.00 - that means your out of pocket maximum would be $4000.00.

So 22,000.00 minus the $2000.00 deductible leaves us with $20,000.00

20% (your responsibility of the co-insurance) leaves you oweing $4,000.00 of the $20,000.00 - BUT because we have a $2,000.00 co-insurance maximum you only pay that $2,000.00 and the insurance picks up the other $2,000.00 that would of been part of your 20%.

So your out-of-pocket maximum has been met totalling $4,000.00 of the $22,000.00 bill - even if that bill was 40,000.00 you'd still only pay the $4,000.00 for in-network services rendered.

Sorry for the long explination - it just really helps I think to understand how it all works at the insurance company (they definatly don't make it easy to understand up front lol). I know I wouldn't understand it if it wasn't for my loving, awesome, supportive husband who's super cool.