Advice On Insurance, Surgeons & Facilities for Newbie

[Taylor5 98]

Good Morning Everyone & Happy Friday!

This is my first time on this website as I have recently started researching WLS and would appreciate any advice out there, but especially from those in my area (I am in PA, at the Berks/Chester County line, in between Reading & Philly).

My first question is if anyone started out in my situation: We are self-employed and have "individual" health coverage. We are on IBC with the Keystone Health Plan East *** Platinum Plan, and I am wondering if anyone has ever had this surgery covered by an ***? Just investigating my personal page on the IBC website shows me a list of exclusions, and bariatric surgery is listed as an exclusion. I guess I was just questioning whether that is a flat out, hard rule, or if there are opportunities for coverage depending on circumstances? I know I can't be 100% sure without calling & talking to them, but they have given me bad information about how to get claims reimbursed before that never panned out, so I am not sure I really trust them. I just thought if Anyone had used KHPE to pay for their surgery, it would give me some hope that it is possible. If not, my husband and I are seriously considering a switch for just me to Personal Choice PPO for January. We were already considering that because of back problems I have so I would have more choices in facilities I could go to, but this could definitely help push the decision over the edge.

The last part of this is wondering what the best facilities are in the area and recommendations for trusted surgeons? Just in my initial searches I am coming up with Barix in Langhorne, who I already contacted and am waiting to hear back from, Main Line Health at Bryn Mawr Hospital, Reading Hospital Bariatric Facility - but more specifically Dr. Leon Kratz, who seems to have an excellent reputation and is closest to me, and then there are a few I have seen in search results but have not actually looked up yet, which include Pottstown Hospital's Program, Abington Hospital's Program, and Wellspan out of the Lancaster area.

Appreciate any advice/feedback you might have!

Thanks,

Taylor (Taylor5)

[Berry78 4,261]

If bariatrics is specifically excluded, then they won't pay for a first procedure , regardless. Your best bet will be switching insurance or paying out of pocket.

I paid out of pocket.. went to Mexico and had it done for under $5000... had a good experience.

@shan0520 might be of assistance...

Oh, and welcome to the board!

[Taylor5 98]

Thank you so much, happy to be here! That is pretty much what I expected, but at least lets me know how much work is ahead of me. Better to be prepared! Congrats on your success so far : ) Have a great day!

[James Marusek 5,244]

If you have the surgery done in the U.S., I would recommend going to a Center of Excellence in bariatric surgery. There are many components to the surgery (initial consultation, surgeon, nutritionist, pre-op testing, training, support groups, five years of post-op follow-ups, etc.) A center of excellence will have all the bases covered. A quick internet search shows that UPMC in Pennsylvania is a center of excellence. It may not be the only one. http://www.upmc.com/Services/bariatrics/Pages/default.aspx

I do not know what the acronym UPMC stands for but here is their contact info.

UPMC
200 Lothrop St.
Pittsburgh, PA 15213-2582
412-647-UPMC (8762)
1-800-533-UPMC (8762)

[Taylor5 98]

James, thank you for your thoughtful help & information. Sorry I did not reply sooner. Somehow I missed that you had responded. UPMC is University of Pittsburgh Medical Center - apparently has an excellent reputation, but a 5-6 hr drive from me unfortunately. But I appreciate the advice on a Center of Excellence! Will definitely keep all in mind as I continue my research.

Have a great day & Congrats on your successful outcome!

[Diana_in_Philly 1,426]

An exclusion is an exclusion, however, you can change policies during the next open enrollment and find a policy which does cover surgery. Work with a navigator or broker. I'm in Philly. Had my surgery done at Pennsylvania Hospital, which is part of the Hospital of the University of Pennsylvania - which is a Center of Excellence. They see patients as far west as Valley Forge. Surgery is in Philly at either Presbyterian, HUP or PA Hosp. I cannot say enough about how wonderful this group is.

Best ofluck.

[Taylor5 98]

Diana_in_Philly,

Thanks for the info - we were actually just notified by IBC that we are no longer in their coverage area now that we moved from Chester County to Berks Co, but since they took so long to tell us we still have to wait for open enrollment. Looks like we will be going with Capital Blue Cross, which stipulates it is a non-covered service "unless medically necessary". All other plans through our broker and on open marketplace for individuals or families do not cover it at all. You have to be on an employer paid ins. plan (with 50 or more employees, I believe, bc we are self-employed and looked at small business plans as well and none of them covered it) and your employer has to choose the option to cover it. I was completely baffled that I did not have the option to add the coverage to my insane premiums which are already more than my mortgage, but apparently in PA that's the breaks.

So, now I will be further investigating how "medically necessary" their medically necessary means for the new plan. If that doesn't pan out, possibly some sort of financing, but seems a little out of reach at this point. Also currently battling severe chronic back/other pain right now and am having to consider spinal fusion surgery, which I don't want to do - especially when I know recovery will be much more likely to have a good result if I am closer to my healthy weight, but since I don't know if I can get the WLS yet I may have to do the back surgery first (I've already had 3, but this is the most invasive by far). Anyway, thank you again for sharing your hospital info. All my current docs are HUP-affiliated in the suburban hospitals they took over, but downtown is definitely the way to go if you can do the commute.

Congrats on your success so far. Looks like you've come a long way : )