What Did You Learn About Insurance? Share Your Wisdom!

[Alex Brecher 10,512]

If you’re lucky, health insurance coverage is fairly straightforward. You know what’s covered, how to get through to an approved specialist, and whom to contact if you have questions.

In many cases, though, health insurance is a big mystery. It’s not always easy to find out what’s covered, what your co-pay is, whether you’re at your deductible, and how to get through to a specialist. Often, people don’t even know where to start to find the information. It can take hours on hold and making multiple phone calls to ask a simple question. Then, when they get an answer, it may be wrong.

Your weight loss surgery may be one of the first times you look deeply into your healthcare coverage policy. What did you discover? Were you able to find out yourself whether it was covered? Did you know where to go for help if you needed it? Did you know which surgeons were part of your network or HMO, and which WLS types were covered?

Please describe your experience dealing with healthcare coverage and share any advice you have for any WLS candidates who may not even know where to start! If you chose to go self-pay even though you might have been covered, what made you decide to do so?

Thanks for helping out some potential WLS patients who may be pretty lost right now!

[Elode 8,093]

First thing I ever did was call my health insurance company (BCBS -FED) and spoke to a live representative. We went over all my questions that I had hand written before calling. I checked each one off as I went through to make sure I asked everything I wanted to know in one phone call. I'm not the most patient person so multiple phone calls was not in the plan. After I got all of my answers I had them email me everything too so there would be no issues down the road. I knew exactly what I had to do to get qualified and I did that. My surgeons office had things wrong more than once. How long I had to do the pre-op NUT visits. What numbers I needed to qualify seeing as I had no comorbids. Luckily I knew so I was able to correct them and keep thing moving at a fast pace. No going back, no submitting paper work at the wrong time, no wrong numbers ect....I was persistent and armed with the information I needed from the jump. 3 months and not one day longer than what I needed to do and I was approved.

[2goldengirl 2,076]

In many cases, you can identify your health plan's medical policy concerning requirements for bariatric surgery by Googling "nameofhealthplan State medical policy bariatric surgery". Then you have in writing what the requirements are for your health plan. Make note of the date of the policy.

In my particular case, my health plan made the requirements easier after I'd gotten started on the process. This led to lots of confusion, as the member services and provider services people answering the 800 numbers weren't always aware of the change.

[wannaBthinsoon 1,634]

Same as @@Elode . I called my insurance company on THE day it was in effect for the requirements from them. I had spoken to others at my company who had the surgery the previous year, so I knew what I had to get done even before I had the coverage (seminar, 6 month supv diet with my PCP, and a co-morbid....so I did a sleep study and had to get a c-pap). So, on the day I had coverage I called our "bariatric resource" dept with our health insurance co. She said I had to go through a COE Bariatric hospital. They assigned me a contact person, who handled everything. I scheduled my appt with the COE Bariatric hospital, who scheduled my Psych visit (on site Psych on staff at bariatric COE!!) and Nut visit, and EGD...all scheduled in the same week. Once psych visit was completed, the psych approved me for surgery, and the next day or two I had the nut visit and EGD (required by COE Bariatric hosp,.....not the insurance co). My surgery was approved within a week after the psych approved me!! My surgery date was a month later! WOW! Typing that all out brought it all back to me. It was such a whirl wind time!!

[jj7481 363]

I started the discussion with my PCP. After that I called my insurance company to find out their specific requirements to have the surgery approved and paid for.

When I started I was referred to a close Bariatric Center of Excellence. I attended their informational session, filled out the paperwork, an waited for a call. They followed up and advised me my insurance viewed them as a Tier 2, and I needed to seek a Tier 1 to have the surgery covered.

This is other thing I would advise people to do is not only ask what is covered, but which hospital they consider Tier 1 coverage or recommend.

Another big point is not to make assumptions that just because you have, for example, BCBS the requirements are the same for your plan. Insurance companies are specific to your employers or healthcare exchange plan. My employer and my wife's employer are both covered by BCBS. However, we are under her insurance because through my employer is several hundred dollars more per month, and doesn't have as good of coverage.

[sharonsjourney 16]

I was surprised to find out that I have to pay all my co-pays, deductables and out of pocket expenses up front to the surgeon's office prior to surgery. The surgeon's office states because this is considered an elective surgery. I'm not sure if this is an insurance rule or surgeon's rule but good to know since my fee's will be several thousand dollars. yikes!

[Daisee68 2,493]

@@sharonsjourney - I don't think they are telling it to you correctly. Frankly if it was elective, it wouldn't be covered by insurance. One piece of advice - do your best not to overpay. What I mean by that is the hospital will ask for an amount before surgery, you will have paid for other tests which eat away at your deductible, etc. So try to keep a list of everything you paid and/or what you remaining deductible / out of pocket costs are so that you can show it to the hospital (or surgeon whomever you are paying last) and attempt to show them you have already paid these amounts. Basically trying to avoid double paying. I will warn you, that you are still likely to double pay, so keep track of everything and what gets paid after surgery because you will likely need to get refunds from the providers. Give them a few weeks after your insurance shows they paid it before calling and requesting the refund.

@@Alex Brecher - My best suggestion is getting the insurance requirements from the insurance company in writing - not just from the doctor. The insurance companies have printed policies and they must be followed to a T. Like @@Elode, I followed everything exactly and had approval in less than 24 hours from being submitted (well submitted at noon on a Friday and got call from my dr office on Monday at 10 a.m. that I was approved.)

[sharonsjourney 16]

@@sharonsjourney - I don't think they are telling it to you correctly. Frankly if it was elective, it wouldn't be covered by insurance. One piece of advice - do your best not to overpay. What I mean by that is the hospital will ask for an amount before surgery, you will have paid for other tests which eat away at your deductible, etc. So try to keep a list of everything you paid and/or what you remaining deductible / out of pocket costs are so that you can show it to the hospital (or surgeon whomever you are paying last) and attempt to show them you have already paid these amounts. Basically trying to avoid double paying. I will warn you, that you are still likely to double pay, so keep track of everything and what gets paid after surgery because you will likely need to get refunds from the providers. Give them a few weeks after your insurance shows they paid it before calling and requesting the refund.

@@Alex Brecher - My best suggestion is getting the insurance requirements from the insurance company in writing - not just from the doctor. The insurance companies have printed policies and they must be followed to a T. Like @@Elode, I followed everything exactly and had approval in less than 24 hours from being submitted (well submitted at noon on a Friday and got call from my dr office on Monday at 10 a.m. that I was approved.)

Yikes! Reposted our posts.... Lol

Thanks for the info! I love this site!

[AnA92212 577]

Called our insurance company. At the time we had BC/BS. However, we live in Alabama and the insurance was from Maryland, but my husband's company was in Virginia. Anyway, after being told one thing and then getting confirmation that we did NOT have to do the 6 month supervised diet, it was fairly straightforward. We had to be 100 pounds overweight and do a psych evaluation. Those were our only two criteria. The first person that answers the phone usually doesn't have the in depth knowledge you need. You have to be persistent. Surgeon submitted paperwork on a Friday, and got approval a week later.

[Alex Brecher 10,512]

Thanks for your answers! Insurance can be pretty tough to navigate, and your answers can definitely help out some of the members who may just be starting the process or who are struggling through it now. Staying on top of it and getting everything in writing definitely seem like “must-dos!”

[DangerMouse007 105]

I have MVP Healthcare in New York, and they actually have Bariatric Surgery listed under the different types of medical issues they cover with costs, etc. As far as how I dealt with the insurance company, I never did. My surgeon's office handled everything from the very beginning. All I had to do was show up. I was never surprised by anything or any of the costs of the co-pays, etc. Everything went very smoothly.

[Sajijoma 1,324]

Some employers especially large corps have insurance liaisons to help streamline the process for their employees and their families. When I had my surgery and even before, I was contacted by this person to make sure all my needs were met and I didn't have any concerns or fears. Even after the surgery, she called to check how the surgery went and if I fully understood my post op instructions and if I needed her help getting anything I needed. I wished I had known such a thing existed before.

[sharowna 6]

Is there anyone whose health insurance is Medicaid with spend down? Excess income pd as a deductable. Would like some info please. And I have Medicare also. Iam on disability. Please and Thank you in advance. This site is so good!

[Briardlady 73]

If you have a chance during an open season, look at Kaiser! I started out with FEHB Blue Shield of California. They were agreeable, I went thru a six month "supervised weight loss and informational" course that meet once a month, it was a joke. I would have been having surgery in January, and my cost would have been around $3500 in all the copays (no deductible). When open season rolled around in November, my premium was going to go up 30%. Uh uh. Switched to Kaiser, my premium was less than I had been paying, got into the options program for 12 weeks of classes that actually prepared me for surgery and success, and paid $250 for my surgery. Follow-up care has been great. So glad I switched, Kaiser is so proactive about health care. It's a bit assembly line, but they have their system for bariatric surgery down pat, no surprises, full support.