obese all my life and just got insurance

[taylormomto6 0]

I posted this in the beginners thread, but wanted to post here as well.

obese all my life and just got insurance<!-- google_ad_section_end -->

<HR style="COLOR: #d9d9d9" SIZE=1><!-- google_ad_section_start -->For years we passed on purchasing medical insurance at DHs work because we simply could not afford it, but at we are 45 now and problems are cropping up:ohmy: This is going to cost us 100 dollars a week for just the two of us (The kids are covered under the "Healthy Families" plan) and I'm not quite sure how we'll afford it, but like always, we'll manage. But I figure II need to make the most of the insurance and take this opportunity to get lap band. I mean heck, after surgery my food intake will be restricted and that will reduce the grocery bill, helps cover the cost of insurance:laugh:

Our insurance is Blue Shield Access HMO with no deductable and the policy takes affect April 1st and states Bariatric Surgey as covered when medically neccessary.

I am 5'6" and weigh about 262, so my BMI is over 40. I'm hypothyroid (been treating myself the last 6+ years because of no insurance through mexican pharmacies) and really don't know if I have any real med problems since I haven't seen in a doctor in years.

I have been obese since I was about 20. Been on many diets (at least 30), lost lots of weight and regained just as much (including losing 77 lbs on Atkins in 18 months about 5 years ago). The only time I was treated by a doctor for weight control, I was given Phentermine and I think that lasted 2 months).

Since I am completely new at having insurance at all, I'm not sure where to begin. I have not yet received my insurance card, but when I do, I assume my first step would be to make an appointment with my PCP. Should I speak with her about lap band on my first appointment or should I establish a relationship with her first? Should I request a weight loss program? What if I lose too much weight? I know I can lose weight in 6 months, but it'll be back by 9 months.

Your thoughts and comments will be appreciated.

Thank You, Cindy T<!-- google_ad_section_end -->

[Wheetsin 714]

Hi Cindy, first - just because your plan (insurance) covers bariatric surgery does not necessarily mean it's available to you. You will need to check your SPD (should be an "Exclusions" section), and may also want to check with your employer directly on employer-enforced exclusions. You will also want to call your carrier and ask them about specific requirements: e.g. weight history, medically supervised diet, etc.

With an HMO you will need to find a primary care physician. Considering your age and that you've not been seeing a doctor regularly, you'll most definitely need a very comprehensive physical, gyn, immunizations, etc.

Medically necessary, by insurance standards, usually means a BMI of 40+ or a BMI of 35+ with 2+ co-morbidities. Often the 40+ requires documentation of co-morbidities as well, more and more it seems. Co-morbidities will have to be found/documented during your physical.

[TulipStar 2]

IMO, I think you should check out to see if there are any lapband seminars in your area. This is the first step that I took (besides researching via internet) and it was very informative. They actually did everything..including getting my insurance approval. I went to 3 different seminars for 3 different dr's until I found one that I liked

Good luck! It will all fall into place. It seems like this is the longest part...getting insurance approval, etc., but it is well worth it!

[taylormomto6 0]

Thank you both for the replies:smile2:

Wheetsin- yes, the first thing is to get the physical for sure. I have already chosen a PCP and will be making an appt as soon as

I get the insurance card.

Tulip- I think that is a very good idea. There are at least 2, maybe 3 seminars in my area. I also plan to attend each one before I ask my PCP for a referral. Thank you so much for the encouragement.

Cindy T

[WhisperLightly 0]

Hi there

I went to the seminar and they signed me up for a visit with one of their doctors (I could have opted to use my primary care physician but I've heard that they don't always know exactly how to document things.. and some insurance companies suuuuure are picky) and with a nutritionist. When I went to that appt, they told me what I needed to get approved (this first appointment is a screening). BCBS (my insurance company) requires 6 months of dietician visits and 3 doctors visits within that 6 months. So you might have to do some requirements ...

The only thing I'm concerned about with you is that... for some insurance companies.. they require that you have 5 years of medically documented proof that you've been overweight and tried, unsuccessfully, to do something about it. Some people can't get the converage just for that lack of proof alone.

Anyways -- if your hospital and surgeon are anything like mine, THEY tell you what you need and THEY have their own insurance "expert" to make you get what you need.. and THEY assemble all your information once you get the requirements filled. They send it off to the insurance and the insurance approves you through them. :biggrin2: I'm learning more and more that every place is different though, lol. So good luck to you! It will all work out.

[Daisalana 33]

Tarylor- Just to re-itterate Wheetsin.. I have BCBS, and as of April 1 last year, they now cover lap-band. However, my policy with my employer, excludes ALL obesity treatments. So insurance would not pay a dime.

Before you sign up for the $100 a week, if you're only doing it right now for the surgery, make sure they cover bariatric surgery. The human resource person who you sign up for insurance with, will know this information.

[taylormomto6 0]

Whisper- I can go have a visit with one of the doctors at the seminar without a referral from my PCP? Hmm, I thought I had to get the referral first with an HMO. See, I'm learning already:laugh: I have BS as well (Blue

Shield Access HMO). As far as the 5 years...if that would be the last 5 years, I'm just out, but prior to that I think there are some records. I did see a doctor for Phentermine and failed, went back to the same doctor after a year on Atkins because my weight loss stopped. He did labs and found me to be hypothyroid. There was several doctors visits involved there. Then a year later when my prescription ran out, I went to the clinic a few times for labs and thyroid meds. Of course, I've had 6 kids in 18 years, so I could get those records that document my weight, not to speak of 25 years of pictures:scared2: I think you are right though, I think I'd have better luck with the bariatric surgeon pushing the paperwork rather than my PCP. Afterall, the surgeon is the one that will get paid, not the PCP.

Fairy- I will check with HR, but the paperwork on coverages I received from the employer states it is covered if "medically neccessary". I do need the insurance anyway though, as there are other issues I need to have looked at (vaginal prolapse, lower back pain, strange skin problems I believe are yeast related and several other lil issues).

Thank You both. You've been very helpful!!

Cindy T

[Wheetsin 714]

Generally info seminars are "free to the public"... think of them as tactics to draw in business. No medical clearance needed since nothing is being billed to your insurance. You can gather info on the surgeon, the procedure, etc. Usually you'll also get a packet to fill out, which is the first step in the proverbial journey. That's where you'll list your insurance information, and what the office will use to begin the process. But whether or not you complete/submit the paperwork, or when, is up to you. (There are differences in how it's done, but I think this is a generic "what to expect")

[taylormomto6 0]

I see. Then if you turn in the paperwork, it will be looked at and decided if they have a good chance at getting paid. If so, they set you up a consultation appointment, I'm guessing for free as well, to kind of "reel you in"?? Will they still need the referral?

Thank You,

CIndy T

[Daisalana 33]

I had 2 consultation appt's with 2 different doctors when I was looking around. Both charged a fee, one was $250 and it was 10 minutes with a nurse who took down my history that I already wrote down for them on their forms (I did not use this doctor), the other was $150, and it included going over the surgery options, insurance info, and an H. Pylori test.

[WhisperLightly 0]

To attend the seminars here (as they are packed full usually) -- you have to have a referral from your PCP. If not at the seminar.. at some point you need a referral.. I don't think insurance (mine, anyway) will cover the "screening" visits to the dietician and doctor if there's no referral in place.

To get ahead of the game -- I called to make a psych evaluation the same day I went to the seminar (it takes forever to get an appt for a psych eval here). But -- like everyone else is saying -- everywhere is different. I've been reading posts where people are saying.. "I looked into the lapband at the beginning of January and was scheduled for surgery 3 weeks later". That is NOT how the process went for me and it had nothing to do with insurance taking forever to approve me. I went through my 6 months of appointments with a dietician, 3 appts within those 6 months with a doctor, I was accepted into the program (i guess at my place they hold meetings twice a month where they look over peoples records and your psych eval and decide whether or not you're a good candidate for the program) -- after ALL that was said and done it was the end of December (I started this in June) .. my insurance got sent out. I was approved in 10 days. So it was basically the very beginning of Jan when I got approved. I didn't get called from the scheduling people until a week and a half ago. So, it's been a long process for me. But understandable. And it could be totally and completely different for you, ya never know.

[Wheetsin 714]

With my surgeon, anyone can come to the seminar. No referral needed, but you do have to sign up to come. You can bring guests. My parents are working on getting banded. They had their info seminar - no cost, no obligation. They've even started their pre-op work (I advised them to wait until they had insurance approval but they decided against). IIRC, the first time there's a charge is during the consultation. The second time there's a charge is when I paid the $20 copay for the surgery to the hospital. Keep in mind tho, that's how *my* insurance did it... I can speak for anyone else's.

Best of luck. And just be sure to ask up-front about fees. I've read some horrible stories about people getting just shy of surgery, then being charged excessive fees they hadn't planned on, and that aren't covered by insurance.

[jena 0]

You actually don't need your insurance card to get started! What you need is the group number and the policy number and the 800 phone number to get in touch with them. You should be able to get this info easily from the HR department. The dr.'s office will call and verify that you are covered!

Ask your PCP to refer you to a lap band surgeon. If your PCP won't do it, change doctors!

[taylormomto6 0]

You guys are so helpful and I'm learning so much.:wink_smile:

Since we've had no insurance and spending our money raising our kids, I had zero chance at getting surgery before. Now at least I can have hope.

I am so sick of trying to convince myself to go on yet another "diet" and dealing with the feelings that I know its just going to be another failure. I've failed so many times that my confidence that anything will actually work is rocked.

I am still fighting the feelings that tell me I won't even be successful with the band. Maybe I'll stop losing again, no matter what I'm eating...maybe I won't be able to control my eating, I haven't been able to yet...and the list goes on. I'm by nature a very positive person, but all the years of diet failure has caused serious doubts in ability to lose this weight. I keep telling myself that these feelings are normal, I mean afterall, each successful bander has failed at diets pre band right??

Anyway, I've rambled long enough:embaressed_smile:

Thank you all,

Cindy T

[WhisperLightly 0]

Cindy --

You can do it!! :wink_smile: Everyone who has the band has it because they've struggled with weight themselves. If you need a pick-me-up... go to the thread at the top and look at the Before and After pics.. talk about inspiration!

The band is a tool you've never had before.. You still have to work hard for it.. but the tool is there to help you, something you've never had in the past. It will be great