Insurance or Self-Pay?

[Kooky1 96]

Last week, my doctor referred me to a Gastric Sleeve Surgeon. I attended his open house and I have a consultation reserved later this month. I contacted my insurance agency because part of their requirements is for me to work with a Bariatric Case Manager. I spoke with her today and she informed me of a few new wrinkles. My insurance company only covers surgeries through a Bariatric Center of Excellence. That doctor is not part of any centers that have that certification.

A few days ago, I stumbled across this forum (and another). I realize that going to Mexico and paying for my own surgery is an actual option. I wrote my doctor and she is discouraging me from this route. She made it clear that my insurance will not pay for any additional surgeries that rise out of complications.

I could go with my insurance but it will take anywhere between 7-12 months before I can have the surgery. Whereas, if I paid, I could probably do it in September or October.

I really, really want to self-pay and do it in September. But, I am also afraid of not being covered for any after-care treatment.

Did anyone else have a similar choice?

[Kindle 8,667]

Don't take your doctor's advice about what surgeries or complications your insurance will or will not cover. Maybe SHE is too closed minded to continue to care for you afterwards, but if your policy pays for WLS it probably pays for post op treatments. Read your policy carefully because it will specifically indicate exclusions. And maybe it doesn't cover complication if you don't have it at a Center of Excellence, but again, read your policy. (BTW, I had my surgery at Obesity Control Center in Tijuana, which is an International Center of Excellence in Metabolic and Bariatric Surgery)

As for me, my policy specifically excludes any obesity treatments, including therapy, weight loss programs or surgery. It also specifically excludes complications from WLS (whether it was done in the US or anywhere else) unless it is for a life saving procedure. For example, it wouldn't cover a scope or other diagnostics if I was having problems holding food down, but it would cover emergency treatment if I had a leak and became septic.

[Kooky1 96]

I thought with the ACA that any appointments after the surgery would fall under pre-existing condition coverage. As my doctor phrased, it would be an elective surgery if I chose to self-pay and the new pre-existing condition change does not apply to elective surgery.

I will call my insurance office and ask about elective surgery in general.

[lylabelle 257]

I could have gone to insurance, most will eventually cover it - but as you said its a year process. I wasn't willing to wait that long. I also did a lot of research, and being a single mom I wanted the best care possible, and with docs here in the US sending people home the same day I didn't think that was possible. I chose Dr Aceves who works out of a hospital (not a clinic) in Mexacali. I read so many good reviews and really knew it was the best way to go. He does 3 leak tests, most in the US get just 1 during surgery. Its 3 days in the hospital to verify things are going well (and because he tests each day). The total (other than my $200 flight to san diego) was $8750. I saved and saved, and there are payment options as well. I had to wait 2 months because of my works schedule but I wished the whole time I didnt have to wait. I was back to work day 6. I'm excited knowing the doc I went to is the doc people go to when they need their bad sleeves fixed! He does such a good sleeve 96% of his patience lose ALL of their excess weight within a year. The sleeve is an art and he does it so well.

As for fear about stuff later. Everyone I've read said problems after going to MX they had were covered by insurance. I was confident since I had 3 full days in the hospital before going, the problems would be caught before I left anyway.

10 days, 13lbs later. Excited to see what the next year brings!!

[Kooky1 96]

Thank you both for your responses. I greatly appreciate your information. I don't know why but I was thinking that I would hear more from people telling me to wait for the insurance to cover it.

I do not want to wait a year for the surgery. But, I'll make sure to have more information about post-surgery care before I make a final decision.

[Shortcake 6]

I went to weight wise in Oklahoma, was 10k cash pay and they had blis insurance you can purchase for 1-2k, I know it's more than Mexico, but was a lot cheaper than other cash pays locally for me

[fearnot 11]

I decided to do self pay also because I didn't want to wait the year for my insurance company requirements. I have checked a couple of different states as to where to have my surgery done. One hospital wasn't sure they wanted to even do the surgery without insurance. In fact I'm still waiting on the call back from them. I found another hospital that I love even better that it doesn't matter if it's self pay or insurance. In fact, if I pay up front then I get a 15% discount. My surgery is scheduled for July 14th....been waiting on a call from the other hospital since April.

[woo woo 872]

I felt more comfortable waiting and going thru insurance. It didnt make sense to jeopardize my family's financial wellbeing (in case of ongoing or serious complications for example) because I didnt want to wait a few months.

It just depends with what level of financial risk you are comfortable with.

[Jersrose43 837]

I am not sure what the rush is nor the issue

Is there something wrong with the center of excellence or is it just the longer weight. Have you considered at least going for 1 visit to a surgeon there and exploring the option?

I am not sure how long you've considered this but this is life changing and sometimes a 3-6 month prep for it isn't the end of the world.

[Asdf12345 12]

Here's the scoop from an insurance perspective. If you elect to self pay, even if your insurance would have covered the operation had you gone through their approval process, the insurance will not cover the cost of any complications as it's considered elective surgery. I was in the same boat, but elected to go self pay becasue I didn't want to wait for the insurance company to OK the surgery. It was going to be a minimum of 9 months for that to happen once I jumped through all the hoops they required. This is also the reason I elected a sleeve instead of a bypass. Sleeves have a much lower rate of complications than bypass surgeries do.

Having said all of that, I know if problems do arise, i will be on the hook for them financially. To this end I selected a Dr. with tons of experience and a good track record of success hoping to cut my chances of any complications.

[LouisianaBawse 0]

I have BCBS ANTHEM and I was told my surgery would not be covered but honestly have the doctors office call insurance for you so they can figure it out with the necessary codes and such bc I was told the exact same thing about my procedure until I had the doctors office call about coverage... good luck!!

[Lifechange>40 22]

My insurance excludes all wls. I still chose a bariatric center of excellence because it included complications insurance for self pay. I was not willing to bankrupt my family if I am in the percentage that has problems. The complication insurance covers you for all extenuating complications for 6 months. I am scheduled with Dr Schmitt, Birmingham, AL.

[Jersrose43 837]

I thought with the ACA that any appointments after the surgery would fall under pre-existing condition coverage. As my doctor phrased, it would be an elective surgery if I chose to self-pay and the new pre-existing condition change does not apply to elective surgery. I will call my insurance office and ask about elective surgery in general.

It's not pre existing condition that applies. It's a clause in many insurances (read your policy fine print) that states complications arising from non covered non authorized procedures are not their responsibility. Many policies have it, many do not. Read yours front to back

[Kooky1 96]

Woohoo! It looks like my insurance may cover any follow-up care.

"Related Care Following Bariatric

Surgery

If you did not receive your surgery under

UMP coverage, the plan covers medically

necessary follow-up care or complications post

bariatric surgery only if:

1. Your surgery was covered by another

health plan or you would have met UMP

criteria at the time of your surgery. You

or your provider must submit medical

records to UMP to show that you would

have met UMP criteria.

2. The procedure performed was one of

those covered by UMP (Roux-en-Y, sleeve

gastrectomy, or laparoscopic adjustable

gastric banding).

If you do not meet the criteria above, followup

care (including lap band fills) or complications

after bariatric surgery are not

covered. If your care was covered by UMP

or meets criteria above, all care for complications

or reoperation must meet UMP criteria

and medical policy.

Panniculectomy (removal of loose skin) is covered

following bariatric surgery for a medical

condition only when specific medical criteria

are met. Most panniculectomies are considered

cosmetic and are not covered."

The only clarification I would like is whether criteria means simply meeting the BMI requirement or if they mean the six month dieting plan requirement.

[Kooky1 96]

I have an answer. The bariatric case manager said that she did not think any revision surgeries would be covered; however, any emergency treatment should be covered.