Just Found Out My Insurance Excludes WLS =(

[chikesweightlossjourney 4]

My last weigh-in is approaching this Saturday and I was very happy about it and still am. I decided to call into today to confirm what was next in this process for me. Mind you I have been going through this pre-op stage since last November. It is a job continue to make routine visits with a job, paying continuos copays only to be shut down. I confirmed that they they found out that my insurance excludes WLS on my policy itself. She did mention that I do have other options. That are seeing to see if they can get the insurance to pay some of the cost, which I'm not sure how this works and stated that I would be left to pay a fee associated with depending on the hospital. Does anyone know anything about this or had every been though something similar? Earlier during me pre-op appointments my doctor did discover that I did have a hernia. I'm hoping they can just run my insurance as a hernia repair, but then go in and perform the surgery at the same token. And advice, suggestion or can anyone relate to this situation?

[LousPeachy 100]

Oh my goodness...you must feel horrible right now. I am so sorry.

I seriously doubt if they would do WLS that way. They would be leaving themselves open for all kinds professional and legal problems. As my exdoctor told me one time, NO patient is worth losing your license over. I would guess all doctors likely feel the same way. Hopefully the dr has some ideas.

Good luck.

Louise

[KateP 359]

Doing two different ops under one code wouid surely be insurance fraud?

I am not familiar with how your systems work but if you end up paying for your surgery, remember the band requires a lot of aftercare and factor in on-going costs.

[Debbie Jean 406]

Doing two different ops under one code wouid surely be insurance fraud?

I am not familiar with how your systems work but if you end up paying for your surgery, remember the band requires a lot of aftercare and factor in on-going costs.

Not at all. The insurance is only billed for the hernia repair. The patient is billed separately at a vastly reduced price for the WLS portion of the surgery. This is an option that several people here have been able to take advantage of when insurance has excluded WLS surgery. It is simply a variation of self pay.

To OP, good luck! You've worked so hard. I hope all the arrangements can be made ☺️

Edited May 8, 2015 by Debbie Jean

[windfaerie 41]

I had to have a hernia repair and another surgery for heartburn. I paid my deductible ($2500) and $5000 to the hospital for the bypass fees. My doctor took his payment from the hernia repair and the other procedure. The insurance was billed nothing for the bypass.

[KateP 359]

Doing two different ops under one code wouid surely be insurance fraud?

I am not familiar with how your systems work but if you end up paying for your surgery, remember the band requires a lot of aftercare and factor in on-going costs.

Not at all. The insurance is only billed for the hernia repair. The patient is billed separately at a vastly reduced price for the WLS portion of the surgery. This is an option that several people here have been able to take advantage of when insurance has excluded WLS surgery. It is simply a variation of self pay.

To OP, good luck! You've worked so hard. I hope all the arrangements can be made ☺️

Fair enough! Your system is baffling to foreigners!!! I think mainly because of different companies doing different things - there has just been a thread on this very topic on another U.S. board I go on and everyone there was saying it couldn't be done! Hope the OP gets it this way!

[windfaerie 41]

Doing two different ops under one code wouid surely be insurance fraud?

I am not familiar with how your systems work but if you end up paying for your surgery, remember the band requires a lot of aftercare and factor in on-going costs.

Not at all. The insurance is only billed for the hernia repair. The patient is billed separately at a vastly reduced price for the WLS portion of the surgery. This is an option that several people here have been able to take advantage of when insurance has excluded WLS surgery. It is simply a variation of self pay.

To OP, good luck! You've worked so hard. I hope all the arrangements can be made ☺️

Fair enough! Your system is baffling to foreigners!!! I think mainly because of different companies doing different things - there has just been a thread on this very topic on another U.S. board I go on and everyone there was saying it couldn't be done! Hope the OP gets it this way!

I got mine done a year ago by going that route. My insurance covers nothing for any type of weight control. But is does cover hernia repairs and heartburn surgery. For straight out of pocket my quote was 22,000 for WLS going the route I did it was $7500. I was getting esophageal erosion so had to have something done for the heartburn immediately so it was only a few months from first visit with surgeon to the surgery date. Mainly the time it took to do all the testing.

[Bndtoslv 292]

I agree that this is the best option. I had a similar situation once. I had two surgeons performing two procedures on me during one operation even. One was covered and one was not. The hospital billed the in-patient care, the covered surgery and the anesthesia to the insurance company for what was covered and this was the most expensive part. The only portion I had to pay was the surgical fee for the second surgeon. The only thing I do not know is what would happen if there were complications from your bariatric surgery. Also after care might be very expensive… Things to ask the bariatric surgeon.

[makemyownluck 785]

I really hope they can find an option for you!!!

I'm honestly shocked that they didn't confirm your coverage BEFORE starting the process. I mean, each insurance has different requirements, I would *think* they would need to confirm what your specific plan required to be approved, at which time they'd know it wasn't covered.

It's not unheard of to get some of it covered when you're having other medically necessary surgery. Instead of making you have 2 surgeries, they will just bill your insurance for the anesthesia and meds and you'll pay for the procedure portion of the WLS.

This actually happens a lot. For example:

You have a major medical plan that doesn't include dental coverage. You need oral surgery for a tooth abscess. They don't pay for the surgery because it's not a covered benefit, but because you have an infection, they can pay the anesthesia portion.

Or, you want a Tummy Tuck. Your plan doesn't cover abdominoplasty because it's considered cosmetic. BUT if you have low hanging skin that causes rashes/infections, that could be covered for a paniculectomy (removal of skin only, not tightening of ab muscles which is what makes it different from abdominoplasty). So they approve the paniculectomy and you pay extra for the "tummy tuck" cosmetic portion, which is minimal because the majority is covered under the insurance for OR, supplies, etc.

[chikesweightlossjourney 4]

Thanks to ALL for your advice and responses so far on this topic. I finally had my appointment last weekend and everything was clarified! WLS is excluded in my policy only as a whole. However, my insurance does cover "Hernia Repair" which is key! It was please with my weight-loss so far during my pre-op journey that for the safety of myself he wants me to loose 30 more lbs before moving forward with surgery. Once this is accomplish; not only will the Hernia Repair be done, he will also go in and perform then worthy loss surgery as well. The Hernia Repair will be covered under my insurance and depending on what fees the Hospital Draws up for me will determine how much I will have to come out of pocket for the weight-loss portion of it all. I thought that this was a great option. I was discouraged at first but since he is a Board of Excellence Doctor, I know he would only recommend the best! Now only does this gives me a chance to loose more weight, but also a chance to save me more to go towards the fees that's will be associated.

Thanks again everyone!

[LousPeachy 100]

That's FANTASTIC! I am so very happy for you!

I meet with the surgeon next Thursday. With the number of WLS's he has preformed, he should pretty well know if Medicare will approve it.

Again, CONGRATS on the good news!

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[Tony Patz 4]

Could somebody please give me the name of the surgeons that work this program?

[Menelly 56]

Doing two different ops under one code wouid surely be insurance fraud?

I am not familiar with how your systems work but if you end up paying for your surgery, remember the band requires a lot of aftercare and factor in on-going costs.

Not at all. The insurance is only billed for the hernia repair. The patient is billed separately at a vastly reduced price for the WLS portion of the surgery. This is an option that several people here have been able to take advantage of when insurance has excluded WLS surgery. It is simply a variation of self pay.

To OP, good luck! You've worked so hard. I hope all the arrangements can be made ☺️

Fair enough! Your system is baffling to foreigners!!! I think mainly because of different companies doing different things - there has just been a thread on this very topic on another U.S. board I go on and everyone there was saying it couldn't be done! Hope the OP gets it this way!

Don't worry, our system is baffling to most of us too. :/