I have Aetna PPO and I was wondering what I’d have to pay out of pocket. We have a 15% coinsurance.

[Tstone83 3]

I have Aetna PPO. I was trying to get an estimate of what I will have to pay for the actual surgery. Anyone else have Aetna PPO?

[GradyCat 3,693]

That all depends on how much your surgeon charges and your hospital charges. They vary by doctor and location. I heard $25,000 was a ballpark estimate on total costs. My surgery was $53,000 but of course insurance didn't pay full price and only paid like $25,000 and my out-of-pocket was less than $1,000

[SusieQ2019 567]

I have Aetna EPO plan and my deductible is $1,000.00 plus $50.00-$60.00 for some doctors visits.

[RickM 1,747]

Nobody here can really say, (without a crystal ball, lol) The costs are quite variable depending upon what procedure you are having done, where, what hospital or clinic, in network or out, etc. Self pay costs, which are a better gauge of actual costs as opposed to what is "charged" and then discounted, are usually somewhere between 10k and 20k for a VSG, somewhat higher for an RNY or DS. Your best bet is to talk to the insurance coordinator in your surgeon's office to get an estimate.

Timing and other medical expenses that you and/or your family incur can influence things as well - my surgeon was out of network for Aetna, but by the time they paid off, we had met our policy's max out of pocket limit, so they paid it 100%. It's a big YMMV thing.

[Panda333 276]

Hello, I have Aetna POS II. I'm still in pre-surgery and have been reseraching this. My deductible is $2200 but out of pocket max for in network is $6,000.00. mayo clinic is in network for aetna so my cosgt will be $6000.00 That's why I'm considering mexico it's $4200.

[jg7979 48]

The best estimate is your out-of-pocket maximum. Between the scopes, scans, and pokes to get cleared for surgery and the actual surgical costs, you are going to reach the max. My advice is to start the process soon to keep all of the costs in the same year, or wait until next year and max out your HSA/FSA contributions to pay for it.

Before I signed up, I did not realize all of the pretesting that was needed--ultrasounds, x-rays, lab tests, ekg/cardiac, stress test, endoscopy, sleep study, psych clearance, nutrition classes. There were several thousand dollars in bills before I was ever approved for surgery. I have Aetna PPO and they require you to use a facility they designate as a center for excellence, so the requirements may be higher than the non-insurance/cash programs.

I have been billed about $20k for the actual surgery (hospital, surgeon, anesthesia), but insurance has reduced contracted rates. I will likely receive a couple more bills, but my out of pocket for surgery is about $2500 because I already spent $2000 on the other expenses (not including nutrition classes).

The hidden costs: All of these appointments and tests require substantial time away from work. Lean Protein and fresh vegetables cost more. Protein Shakes, protein powders, supplements, etc. add up quickly (and you will want variety). I will save on prescription costs though since I will not need several medications anymore.

[Tstone83 3]

How long did it take to get your approval?

[jg7979 48]

28 minutes ago, Tstone83 said:

How long did it take to get your approval?

It was 2-3 weeks after my last nutrition class. I didn't even know it happened.

When I received the letter, I called the surgeons office to ask if they needed anything, and they said I was all set. Insurance just sends the standard letter, but no news is good news when it comes to approval.

[Panda333 276]

On 3/30/2019 at 3:40 PM, Panda333 said:

Hello, I have Aetna POS II. I'm still in pre-surgery and have been reseraching this. My deductible is $2200 but out of pocket max for in network is $6,000.00. mayo clinic is in network for aetna so my cosgt will be $6000.00 That's why I'm considering Mexico it's $4200.

Found out mayo is "not" a center of excellence and it turns out Advent Health is which they told me on the phone it wasn't. This is a frustrating journey and like a full time job. My Co-pay now will only be $476.00 (after my 2200 deductible. Wow.

[jg7979 48]

44 minutes ago, Panda333 said:

Found out mayo is "not" a center of excellence and it turns out Advent Health is which they told me on the phone it wasn't. This is a frustrating journey and like a full time job. My Co-pay now will only be $476.00 (after my 2200 deductible. Wow.

Here is my list of charges that are pretty much in order leading up to surgery:

• Surgeon Consult (Specialist Copay)
• Nutrition Consult (Cash Payment)
• Initial Blood/Labs –26 labs + urine (Provider billed $682)
• Cardiology Consult w/ EKG (Specialist Copay)
• Abdominal Ultrasound (Coinsurance)
• Upper GI X-Ray w/ Barium Swallow (Coinsurance)
• Chest X-rays 2 views (Coinsurance)
• Upper GI Endoscopy plus facility, anesthesia, and pathology (Coinsurance) Providers Billed $2100.
• Surgeon Visit for monitoring (Specialist Copay)
• Nutrition Class (Cash Payment)
• sleep Specialist (Specialist Copay)
• CPAP/Apnea Overnight Study (Billed as specialist copay) + Interpretation (Coinsurance)
• Psychological Consult/Evaluation (Specialist Copay)
• Nutrition Class (Cash Payment)
• Minor Bloodwork for Pre Anesthesia Testing (Billed $6)
• Pre Anesthesia Testing (Specialist Copay or PCP Visit)
• Nutrition Consult (Cash Payment)
• Surgeon Office Visit (specialist copay)

The actual surgery is not included. This is just to meets Aetna's requirements and get approved for surgery.

I also did not have to see a pulmonologist, nor did I have to get a cardiac stress test (had one a few years ago).

[jg7979 48]

54 minutes ago, Panda333 said:

Found out mayo is "not" a center of excellence and it turns out Advent Health is which they told me on the phone it wasn't. This is a frustrating journey and like a full time job. My Co-pay now will only be $476.00 (after my 2200 deductible. Wow.

If you have access to Aetna's website, you can access the list of providers.

aetna-ioq-bariatric-guide.pdf

[Panda333 276]

16 hours ago, jg7979 said:

Here is my list of charges that are pretty much in order leading up to surgery:

• Surgeon Consult (Specialist Copay)
• Nutrition Consult (Cash Payment)
• Initial Blood/Labs –26 labs + urine (Provider billed $682)
• Cardiology Consult w/ EKG (Specialist Copay)
• Abdominal Ultrasound (Coinsurance)
• Upper GI X-Ray w/ Barium Swallow (Coinsurance)
• Chest X-rays 2 views (Coinsurance)
• Upper GI Endoscopy plus facility, anesthesia, and pathology (Coinsurance) Providers Billed $2100.
• Surgeon Visit for monitoring (Specialist Copay)
• Nutrition Class (Cash Payment)
• sleep Specialist (Specialist Copay)
• CPAP/Apnea Overnight Study (Billed as specialist copay) + Interpretation (Coinsurance)
• Psychological Consult/Evaluation (Specialist Copay)
• Nutrition Class (Cash Payment)
• Minor Bloodwork for Pre Anesthesia Testing (Billed $6)
• Pre Anesthesia Testing (Specialist Copay or PCP Visit)
• Nutrition Consult (Cash Payment)
• Surgeon Office Visit (specialist copay)

The actual surgery is not included. This is just to meets Aetna's requirements and get approved for surgery.

I also did not have to see a pulmonologist, nor did I have to get a cardiac stress test (had one a few years ago).

This is super helpful - Thank you! Wondering if I have to do a an overnight study as I do not have sleep apnea?

[SusieQ2019 567]

Take into consideration that there are different types of AETNA insurance plans and what is required. I have Aetna and there are things listed on the above that I did not need to do or was not required to do. It all depends on the plan your company have. For example my deductible is $1000 and and I am responsible for 10% after I've reached my deductible. The surgeon had a specific list of what my plan required.

One type of Aetna insurance plan do not fit all.

Wishing you good luck with your surgery.

Edited April 23, 2019 by SusieQ2019

[jg7979 48]

You probably wouldn't need the sleep study/consult then... like SusieQ said, it is a little different for everybody. I was fortunate that I did not have to see a pulmonologist or have a cardiac stress test. Some of the requirements may also be related to the surgeon's selection criteria and not just insurance approval.

http://www.aetna.com/cpb/medical/data/100_199/0157.html This is the clinical policy bulletin that describes Aetna criteria to qualify-- every member must meet either have a Physician-supervised nutrition and exercise program (6 months over two years) OR Multi-disciplinary surgical preparatory regimen (90 days).

I did the multi-disciplinary regimen which was a busy 90 days.

obesity-surgery-precert-form.pdf

[GettingDHealthy 6]

I’m on Aetna PPO and got denied this week even though I meet all of the requirements for surgery. They said that bariatric surgery is not covered under this plan 😞