Kaiser Oregon - Not Covered?

[saoirse16 1]

Hi everyone! I'm looking into having weight loss surgery and called Membership Services today to verify coverage and costs, and ask about the process before scheduling an appointment to get things started - but I was told that weight loss surgery of any kind is not covered.

From what I understood in my plan details, weight loss surgery is not covered unless it's medically necessary and/or if I meet other requirements, and when I brought that up to Membership Services, they said I was not covered, period. She just kept repeating, "that procedure is not covered" as an answer to my questions. Rude.

So I called OHSU to discuss their self-pay options and they were shocked that Kaiser had told me I wasn't covered. OHSU had not heard of that happening before, and highly recommended that I contact Kaiser again.

Before I call Membership Services and get treated rudely again, is there some other department I should call at Kaiser instead? Is there some process or way of getting this covered by Kaiser that's not being offered to me?

I've looked at the Kaiser website and it's not offering much in the way of info. I did find info that bariatric surgery is done at Kaiser, but no info on how to get to the point of actually having the surgery.

Not sure where to go from here...any suggestions?

[petesmom 8]

You could always go to Mexico

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[saoirse16 1]

Oh yes, I should've mentioned that I've been looking into Mexico too. But I'm concerned about post-op care/followups and getting that covered through Kaiser. Not sure how all that works? Especially if there's a serious issue some time down the road after surgery.

[petesmom 8]

I am currently looking into Medical Tourism ins. Reading the fine print. I so have a few questions. Otherwise chances are if your insurance does not cover surgery it will not cover bariatric or anything after surgery when you get back home. The chance of something happening is pretty slim but it does happen.

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[Jdserra 78]

Hmmm that's odd...out here in CA it's covered as long as your primary refers you and you meet all the medical criteria.

[petesmom 8]

I was talking about if you have surgery in Mexico and need to be treated back in the United States for aftercare. Most insurance companies won't touch you most emergency rooms have to accept you and treat you but your insurance does not have to pay for it most likely they will refuse as a result from surgery out of the country

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[sleevemebe 2]

I'm getting my sleeve at Bay Bariatrics in Coos Bay, Or. They have an affordable cash pay option and he's an excellent surgeon.

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[saoirse16 1]

@SarahWood Thank you! I'll look into that facility & surgeon as well.

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[FarmerJulie 5]

I am three weeks out. I had gastric bypass at Kaiser Sunnyside. Are you in the Portland area? Mine was definitely covered! It's a huge program. Takes a while to get through. With Kaiser the first step is a referral from your primary, so go see them. I am guessing Member services was getting it wrong.

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[Fredbear 397]

Coverage depends on your actual plan (Kaiser is not a "plan" it is a provider). If your coverage includes Bariatric, then it will be covered; if it excludes it, it will not be covered.

[saoirse16 1]

I do understand plan vs provider. The parts where I'm stuck are (1) my plan info says something different than what Membership Services told me, (2) I thought maybe I called the wrong department to start and shouldn't have started with Mbr Svcs but possibly a different department, and (3) I don't know where to start with the process, and haven't found definitive info on specifically pursuing bariatric surgery.

I started with Kaiser recently, and their system in general is not what I'm used to & has been quite confusing at times.

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[highfunctioningfatman 2,675]

Call the bariatric facility of your choice and have them verify your insurance coverage. They will be able to use the appropriate billing codes to determine coverage. We do that all of the time in the oxygen industry. Back in 2000 my sister had gastric bypass and in 2001 my mom had gastric bypass in Coos Bay. I had VSG 12 weeks ago in Mexico. I wasn't concerned about follow up care. I researched the crap out of my surgeon and found that he had a zero complication rate. I couldn't find anyone here like that. I also met 5 other people here locally that have been to him. Three of the five are in the medical field all they all said the it was the absolute cleanest facility that they have ever been in. I am in Southern Oregon.

[shedo82773 1,236]

I'm getting my sleeve at Bay Bariatrics in Coos Bay, Or. They have an affordable cash pay option and he's an excellent surgeon.

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Hi Sarahwood26,

I had Dr. Tersigini also. I had my RNY on July 2, 2013. Yes, he is an excellent Surgeon but I found him lacking in bedside manners. He also did my hubby's failed revision from Lap Band to RNY. He was so sick and almost died. He developed Abscesses and was so sick for 9 months, 3 of which he doesn't even remember!! Dr. Tersignini dropped him in the middle of everything!! Luckily, our PCP had been following what was going on and pulled a favor in from his friend to do his surgery to put the Wound Vac in. Dr. Tersigini called us the "PROBLEM CHILDREN'. I really liked his office personnel and his PC. We both stopped going to him. But not before my hubby went back to try again (yes he stll was going to let him do the RNY) but was told that he wasn't going to do his surgery. We both go to OHSU now. I hope everything works out for you. I just wanted to let you know how it all went down for us. BTW I had problems with Strictures that is why he called me a problem child. Which is no reflection on me, no one knows who will have problems.

[shedo82773 1,236]

Oh yes, I should've mentioned that I've been looking into Mexico too. But I'm concerned about post-op care/followups and getting that covered through Kaiser. Not sure how all that works? Especially if there's a serious issue some time down the road after surgery.

My hubby had his surgery in Mexico and OHSU Bariatric Center will provide him with medical care. It isn't as hard as people think to get a DR. I had my surgery in Coos Bay, and they took me on right away without a problem.

[necarv 4]

It is definitely covered here in California. You could ask for a referral from your PCP to the bariatric program and then talk with the case manager. They might be able to help with verifying coverage.