Why has Tricare denied gastric sleeve?

[mswanson502 0]

When I went in for a consultation, I was told that Tricare no longer covers the gastric sleeve at all. I am SO upset. That's what I was going to have. They used to cover it. Why the change I wonder?

I'm definitely not getting the Lap-Band. I know 4 people that have had it, and not one of them lost more than 20 pounds and then gained it back even with adjustments. So I'm left with the gastric bypass which has many more complications. But there's nothing else to do I guess. : (

[Amanda626 153]

I was a self pay sliver since my insurance covered neither. If theyvwould have covered bypass I would have it right now lol. Results almost identical.

[cbd 78]

Can you change insurance? My husbands insurance covered it but was an *** and You had to travel fours hours for all the meetings, appoint., surgery, follow up. I changed to the insurance offered at my work last July and was sleeved in Jan. It put surgery off a few months but was worth it. Good luck

[mswanson502 0]

How much does it cost being self-pay?

Unfortunately I cannot get new insurance. My husband is military, and I'm not working. : (

[healthy2bmomof3 0]

I am in the process right now, if you only have Tricare you have to have it done at a participating MTF, you get a referral from your PCM to the general surgery/bariatric program at a participating MTF. Once that MTF gets the referral the surgeon and his coordinator decide if they want you- it was explained to me kind of like it is a practice surgery they don't do many (at least at the 3 MTF's I called before deciding where I would try first). It is completely up to the surgeon & the criteria set at the individual place. They still send the referral but because Tricare doesn't re-imburse a MTF it technically isn't "covered" by tricare but there really isn't an expense. You can PM me for more details, I am not accepted yet but they are reviewing my record and referral, this is what the bariatric coordinator at the MTF told me. I do not want a band or RNY so if I am not approved after trying all 3 MTF's that are close by I will self-pay.

About the self- pay I was concerned about not being covered for any complications and was assured by Tricare if something arose it would be covered.

[mswanson502 0]

Thankfully I have Tricare Standard and can go about anywhere. I have to pay 20% though. It will be worth it! I don't think I could self pay. It's gonna be hard just covering the 20%.

[Guest]

I got an estimate today for the VSG since I am also a Tricare patient. Facility charges are $46,000 alone. I definitely can't afford this procedure without insurance but I am set on the sleeve, I don't want the RNY or Lapband.

Our MTF is just starting to do bariatric procedures. (Few months away) May be my only chance.

[mswanson502 0]

OMG! $46,000 or more? That's horrible. If it's that much, I can't even afford the 20%. Eek!

[Kristina J. 581]

Self pay if you went to Mexico (there is a lot of information on the self pay/Mexico board) is generally anywhere from $4-9K depending on location and surgeon. Most people seem to average around $5K.

The best I've seen for self pay in the US was around $10K, so if you're not comfortable going to MX then there are self pay options in the US, and though you would likely still have to travel, it's not out of the country. They're more expensive than MX, but nowhere near the $44K mentioned.

My insurance (expensive and usually great insurance) doesn't cover ANY bariatric at all. I chose Mexico because the hospital is 45 minutes from my parents house in San Diego and I am more confident in this doctors experience with lap band to sleeve revisions than the self pay doctors I talked to in my area (and he was much less expensive than my area as well obviously).

[Guest]

I live in Alaska. Probably why the price is ridiculous.

[mswanson502 0]

Oh ok. Yeah, that's def it. When I Googled prices in the US, it was around $25,000. But I have no idea if that included hospital costs. I'll find out hopefuly Tuesday.

[Kristina J. 581]

Well here's what happens when a hospital charges. They send a bill with all their costs (I've heard of as high as 80-90K for this surgery!!! Then, the insurance company applies their negotiated contractual "caps" or "limits."

So, for example, my hysterectomy bill came in around $37K, my insurance capped it with their negotiated pricing at $18K and paid a total of $17,500 leaving me with my $500 deductible. Does that make sense??

So, if you call just an average hospital and ask their "self pay cost" they are going to give you that top number... In the example of my hysterectomy, $37K. However, if you call a hospital or surgical team that specifically provides self pay options, generally they are more in line with the insurance pricing!

So they may be quoting you $46K, but would only charge insurance $25K.

And it's based on THAT pricing that the average self pay in the US is closer to $20-25K. Though some places have streamlined the process and have their cost as low as $10K or so for self pay (a lot to do with the cheaper Mexico competition), even in the US.

Whew... You ladies with me?? Lol

[Guest]

Yes, I know about contractual adjustments-

This charge is facility, no discounts for self pay other than a prompt pay discount I can get, (20%) but 46k is a joke. I can't imagine what people do without insurance... Honestly that's all I thought about all afternoon.

[Kristina J. 581]

Yes' date=' I know about contractual adjustments-

This charge is facility, no discounts for self pay other than a prompt pay discount I can get, (20%) but 46k is a joke. I can't imagine what people do without insurance... Honestly that's all I thought about all afternoon.[/quote']

Yeah, if you're even in a position to consider self pay, you don't want anywhere that doesn't do a self pay discount. Most local hospitals won't. You'd have to go through a specialty group. Even with great insurance I'm not covered for this. My parents don't have health insurance at all and face this stuff all the time! Thank goodness for self pay medical clinics. They can see a doctor for under $100!!

[mswanson502 0]

Well, I had my appointment Wednesday. He recommended I get the bypass due to my health and challenges. So that's what I'm going for after some thought. I had my scope done Friday to check for h pylori. I was asleep when he came in, but all my MIL was told was that I had a hernia, gastritis and an ulcer. I was sent home with a Rx for something. He didn't say if I had h pylori or not. I'm scared I may. I really don't want to put this surgery off another 2-3 months. I need to be completely healed by July. How long does it usually take to find out the results of the h pylori test? Any idea?