Newbie with Insurance questions!?!

[riisey007 10]

Hi there I am new to this forum and I have a lot of jitters concerning insurance. First let me tell you my dilemma I have BCBS OF Alabama. My employer has 2 plans one of them is the cheaper plan where you have to see your pcp in order to get a referral to see a specialist. I am on this plan, in November during open enrollment I will be switching to the higher cost plan due to the plan I currently have excludes bariatric surgery and anything to do with it. Once I change in November it will become effective in January 2014. I am nervous because I have decided to go ahead with the 6 month diet, I have seen the nutritionist, I have my photos proving I have been obese( I am using photos because I don't have 3 years of morbid obesity in my chart, it is not written specifically). I am hoping that I have not done all this in vane. I was hoping to get a jump on things and be able to have the surgery in January or February. Has anyone had to change insurance like I have and not had to repeat the diet etc? also did anyone submit photos and if so were the 3 years prior to your surgery or submittance to insurance or can it be random photos over the years? I have called bcbs and they arekind of evasive and I know they do that on purpose. I don't want anything to go wrong because I am really taking a big chance by changing to an insurance that is way too expensive and if they approve me or not I am stuck paying it for at least a year. If anyone has any advice please let me know. Thanks so much and thanks for letting me be a part of this warm community. Theresa

[oldoneyoungagain 200]

Yes, the insurance company can be very evasive. I found out in May that my band had to come out. When I found it out the surgeon and I discussed the next step which was RNY. I explained to the case manager that effective 6/1/13 I would have different insurance and told her which one. She said I would have to have three months of weight management, so I started the process. Band came out 5/23/13 had one weight management through my PCP done and will have my three months of that completed in July. Started with the dietitian in June will complete all that by August. So I actually started what my new insurance wanted prior to ever having the insurance. One good resource is your bariatic surgeon's office. If you have a good group they can tell you what your new insurance requires, that is if they accept that insurance, as they get to know every insurance they accept and know exactly what the insurance companies want. Requirements for most all insurance is at least 100 lbs overweight, BMI of 40 or more, or a BMI of at least 35 with co-mobidities (diabetes, high blood pressure, sleep apnea and the list can go on). The other is that you basically have tried dieting over the years but what you lose you put back on plus. So you can start your diet now (my doctors had proof of last December but needed two more, went ahead with three since by doctor also requires a dietitian and a class on do's and don'ts and what to expect with RNY). But if you want positive reassurance exactly what that insurance wants talk with the bariatic center's, as I said they know. Hope this helps.

[LindsJ83 56]

Hi Theresa - This is my opinion and best educated guess: Because your current insurance plan does not cover bariatric surgery, there is a very real possibility that when you switch to your new insurance plan during the open enrollment they will require you to start from square one. There are two distinct scenarios here and I will give you both: Scenario 1 - Your insurance is effective January 1, 2014 and you have done mostly all of what you need to do. Your surgery will be scheduled soon after. Scenario 2 - Your insurance is effective January 1, 2014 and you have done mostly all of what you need to do. Then, you find out you have to start all over again. All insurance companies won't lay things out for you so that's really why you need to rely on your surgeon and his office to take care of your stuff so that 1rst letter of approval will come through. Do you have a surgeon picked out already? Have you gone to an informational session? More importantly, seeing a nutritionist is a wonderful thing to do however, most surgeon's offices have an on-site RD that you are REQUIRED to meet with at least once before your surgery. As far as photos go - the more ammunition you have for the insurance company, the better. But, keep in mind that your visits to your PCP MUST include your documented weight/health at the time of the visit. They need to be for at least 6 months in conjunction with your PCP and/or RD. You sound a LOT like me when I started: I am a planner, I don't like surprises and I like to get as much out of the way as possible. So, it practically killed me knowing I had to wait...and wait some more...and more. This is what I can definitely promise you: As each day passes, you will be more sure in your decision to do things. My surgeon's office said the quickest they have seen someone go through the process has been 3 months. Insurance approval is completely separate from what a surgeon's office asks of you. They are all different. I have heard someone having to write 5 or 6 different essays, contacting post-op patients, etc. You will also need clearance from multiple doctors in different areas of specialty. For most patients, they need an upper gi series, an ultrasound, an endoscopy. Some need pulmonary, cardiology, sleep testing. For all patients, they need labwork. All of these obviously go beyond insurance requirements and approval. The best thing you can do is: Pick a surgeon if you haven't yet, go to an informational session, support groups, find out about this new insurance as much as possible so that when January does come - you are at least 10 pounds lighter (you will need to lose weight anyway before surgery so your liver is the healthiest it can be) and you have ammunition for the surgeon/insurance company. Unfortunately, there is no real yes or no answer. This is a life changing decision, so remind yourself every day that it will take some time to get everything figured out. I hope this helps a bit! And, good luck and love to you. All my best. -Lindsay

[Sheri h 18]

Just wanted to say welcome and I hope everything works out in your favor because I know what it is like. went from a job that the insurance stop covering the surgery right before I started in 2000 to my present jobs insurance just did a pilot program and I was one of 100 that was granted the chance to have surgery april 10, 2013 was my new journey's beginning.

[riisey007 10]

Thanks everyone, you guys are great. I wanted to answer a few questions because I left out some information. I am as someone said above a planner, I am a medical professional who works for a hospital and I have been on the management side of my field so I know insurance and that is why dealing with them makes me nervous because they have power over the future of my health. First thing, I am not changing jobs, I am still going to be at my present job and I am currently covered under their bcbs and as of November during open enrollment I will be changing to the other plan that my hospital offers that is more expensive but covers bariatric surgery. I called Human resources and they told me to do it this way. I was referred by my pcp to my current bariatric surgeon and he is great. I am on my 6 month diet with 4 months left. I went to my surgeons conference and was very impressed, I made an appointment at the seminar for a consultation. I have been to my consultation and their insurance department has already told me that my current insurance does not cover bariatric surgery but I knew this already! I spoke with bcbs twice and I called HR to be sure. My surgeon and his team knows that I am going to change my insurance in November. They were impressed with my research and paperwork from getting my soon to be new plans group number and calling bcbs to verify that it is covered. My surgeon even worked up my lab work so it would be drawn through my pcp in order for me not to have to incur that cost and I am thankful for the blood work, he was very thorough because I found out that my dizziness and stomach issues were not just coming from my IBS-C but from H-pylori..ugh. I am done with my 14 day 6 antibiotics a day therapy and I also am on Vitamin D. The nutritionist that I have been to is part of the bariatric group and is in my surgeons office, she is going to go over pre op and post op diet again in January for me, I have been fortunate enough to have a great pcp and he is a big supporter but I worry about his wording and writing the proper information in my chart. I have told him what is required and he assured me that he is taking care of it and I surely hope so. I received a 6 month packet from my surgeon in which I take 1 month over every month for them to fill out and to be placed in my chart and they give me a copy for the surgeon and I also keep one for my files I am hoping this will be fine but I know that he must also continue to document as well. I have only a psych eval left to do,print off my photos with time stamp on them, finish my 6 month diet, and do the proper paperwork in November. My surgeon has not said anything about the psych eval as far as doing it now but that is ok because I would rather wait until January to do it so it will be closer. HR says the only wait time I have is to be employed a year at the hospital but that excludes me because I have been at the hospital for way over a year and I am only switching and not getting insurance for the first time. My worry is actually having to do everything all over again but my surgeon seems to think it is fine for me to go ahead and do what I need to do and be ready in January. I can't help but worry if I am doing it right because insurance is so evasive and they will only guide you and point to the same material and read it word for word like I hadn't already read it a thousand times. There is pretty much nothing I can do with the surgeon because until I change insurance he can't file anything. My surgeon says that unless I have had heart problems, pulmonary problems etc then he won't require me to go see a cardiologist nor a Pulmonologist. My biggest thing with insurance is that I am scared that I will be turned down because I have jumped the gun on some things or have not covered my bases with proper documentation. Do you guys remember what was written out on each of your pcp diet visits? I have read on several forum how people were turned down due to improper documentation and I don't want that to be me. I have worked up the courage and I am mentally read to shed this fat and live longer than my parents.

Thanks guys for everything. T