Couple basic insurance questions

[CrystalT 0]

I feel like my insurance company is setting me up to NOT qualify. I have short lived success with losing weight. I lose and gain the same 20 lbs. I need an extra tool to help me continue to lose weight. Under the Insurance guidelines Before I can even talk to my doctor for the referral I have to participate in the Insurance Weight Management Program for 6 months. They pay for Weight Watchers for that 6 months. The catch is in order to stay in the program you need to lose 5% in the first 3 months in order to stay in it for the second 3 months. The papers say you need to have 100% compliance in the program. It doesn't say that you have to lose another 5% in that second 3 months.

My current BMI is 45.1

BMI after 5% 42.8

Not sure if by 100% compliance means that in the second 12 weeks I would need to lose another 5%. If so that would make my BMI 40.5

After the 6 months Weight Watchers program then I have to do 6 months of the Bariatric Centers Weight loss Program.

I have no comorbidities so in order to have the surgery I need to have a bmi of at least 40.

My questions

1. Do you think 100% compliance would mean another 5%?

2. In order to qualify for surgery do you have to lose weight in the Bariatric Centers program?

3. Are you approved for the surgery BEFORE the pre-op diet or can you lose too much weight during the pre-op diet and be denied?

I'm ok if its only 5% weight loss at the center if I don't have to lose that in the 2nd half of the WW's program. I know that these probably seem like dumb questions, but I couldn't find the answers and I don't want to ask my insurance company too many questions before I complete the first 6 month program.

[chasingadream 1,311]

Those are great questions…..

but only your insurance company can really answer those specific questions. They are the ones that are ultimately going to approve or deny you.

If it were me, I would call and ask to speak to someone who can help you with YOUR specific questions. I would get their name and ID # or any other pertinent information that you can refer back to if needed. I would also call a 2nd or 3rd time and ask the same question to other reps to make sure all of their answers are the same.

Everyone on here has had such different requirements with insurance companies that any answers would just be conjecture or guessing on what exactly YOUR insurance company is going to require.

And I agree with you…you don't want to go through all of this and then be denied which is why I think you should contact them and be as transparent with them as possible. I know dealing with insurance companies is VERY ANNOYING but better to know what is expected of you up front.

Just my opinion and advise…wishing you all the best….

Let us know how it goes.

[lisacaron 5,075]

I feel like my insurance company is setting me up to NOT qualify. I have short lived success with losing weight. I lose and gain the same 20 lbs. I need an extra tool to help me continue to lose weight. Under the Insurance guidelines Before I can even talk to my doctor for the referral I have to participate in the Insurance Weight Management Program for 6 months. They pay for Weight Watchers for that 6 months. The catch is in order to stay in the program you need to lose 5% in the first 3 months in order to stay in it for the second 3 months. The papers say you need to have 100% compliance in the program. It doesn't say that you have to lose another 5% in that second 3 months.

My current BMI is 45.1

BMI after 5% 42.8

Not sure if by 100% compliance means that in the second 12 weeks I would need to lose another 5%. If so that would make my BMI 40.5

After the 6 months Weight Watchers program then I have to do 6 months of the Bariatric Centers Weight loss Program.

I have no comorbidities so in order to have the surgery I need to have a bmi of at least 40.

My questions

1. Do you think 100% compliance would mean another 5%?

2. In order to qualify for surgery do you have to lose weight in the Bariatric Centers program?

3. Are you approved for the surgery BEFORE the pre-op diet or can you lose too much weight during the pre-op diet and be denied?

I'm ok if its only 5% weight loss at the center if I don't have to lose that in the 2nd half of the WW's program. I know that these probably seem like dumb questions, but I couldn't find the answers and I don't want to ask my insurance company too many questions before I complete the first 6 month program.

Most insurance companies these days require you to be on a 6 month medically supervised diet. Mostly that entails going to your General Doctor and having them monitor your weight loss and/or gain over the course of 6 months on a supervised nutrition diet plan that they give you. (It's a formality) They do it to be sure that you are 100% compliant in that if you don't do this for 6 months the chances that you will use the weight loss surgery tool and be successful with it are minimal since WLS of any type takes 100% compliance on the part of the patient.

You are not going to have surgery, lose weight and live happily ever after never to be obese again. If you do not follow the Dr.'s guidelines along the way and you don't commit to yourself to a life style change 100% the chances of failing are greater.

So they are not asking so much that you lose 5% of your weight during this time but that you comply with the rules, and follow the 6 months take your weights and have the Dr. report on it to them. Submit the paper work they require any testing they require and you should be good to go.

The surgeon's office you choose will have an advocate there who can help you to understand what your insurance company requires for approval and they can guide you through all the steps along the way so your not having to have interaction with the insurance company directly if your uncomfortable with that.

Reach out to the surgeon's office and set up a meeting with their surgical coordinator and see if they can help you sort it all out, they are always an excellent resource to start with.

Edited June 2, 2014 by lisacaron