Eh starting to worry about bmi and getting covered.

[dolly_lala 0]

Well as you can see on my ticker i have a bmi of 39.5, i weigh 230, and i'm concerned about my insurance approving me, a part of me is like you feel so big already how can you get bigger no no no...get it done now.... but then i start to worry about how the insurance company will view it...saying you are on the border even tho you have back problems, we're sorry...

then i'm concerned cause i was just informed that the DR. that my primary is reffering me to may want 5000 up front even tho ihave insurance, i understand how the DR. is covering his butt making sure he gets paid but I just dont have thatkind of money, i'm still thinking how in the world i'm going to do the co-pay whatever it might be... it stinks cause i'm not concerned about the surgery itself at all, but the fact that i either wont get approved for my insurance, and or the surgeon wanting several thousands of dollars upfront...yikes...i'm worried..:cool:

[kaninag 35]

First off I would NEVER go to a dr that requires 5000 up front. If your insurance approves this surgery you shouldnt have to pay anything but your copays and deduct. if you have one and then if its not covered 100% your percentage. PLEASE dont give him $5k......I'd hate to see your insurance deny you and then the dr wont refund your money....These docs that are requiring money up front before seeing if your insurance will even pay are just looking to make a quick buck and not only are they prob getting paid by your insurance company but then theyre charging you too.......FFFFFFFRRRRRRAAAAAUUUUDDDD!!!

as for the BMI do you have any comorbidities???

[lafrogura 0]

:rolleyes2:I agree! That sounds like frauuuud... even if your insurance covers it, there's no reason for them to charge you that much up front. If you really want to use that doctor, then i suggest you call your insurance and find out what your responsibility is for the hospital and the surgeon and see what you have to pay up front (eg, deductible, copay, co-insurance) .. that way the insurance can tell you "you have a 500 deductible and then insurance pays at 80% until you meet your maximum out of pocket expense.. i do medical billing for a hospital and there's no way that doctor can charge you that amount unless he is not in-network on your insurance.

[dolly_lala 0]

well the only comorbilities I have are my back problem i have a really bad disc that either requires phyisical therapy, and if that doesnt work surgery, or loose the weight, i'd rather just loose the weight than put myself through back surgery.... and i'm not sure about anything else, i told my doctor my feet go numb when i work out on the eliptical, like i've been laying on them all day long, i'm not sure what that is or why....but i have awesome work outshoes so i know those arent the problem....

Anyways As far as my CYD i've already met that for the year, ours works of of a single person to meet 250 deductable which i have, i had to have an mri for my back earlier this year, as well as went to the ER before then cause of the extreme back pain....

So I know if i qualify my insurance WILL pay 80%, and I the other 20%.. Still not sure what that will be yet, and still trying to figure out how to pay for it If i get it doen before next year, if i have to wait till next year i'll just use my income tax return to pay for it, but i'd like to get the surgery before I finish school and have to start working....

baah i talk alot :cool:

[dolly_lala 0]

heres a bit from my bcbs insurance plan, what i'm trying to understand is....the part in bold...

Deductible/Coinsurance

Calendar Year Deductible (CYD)* Individual

In Network You have met $250.00 of your $250.00 deductible

Out of Network You have met $250.00 of your $750.00 deductible

Family

In Network You have met $485.68 of your $500.00 deductible

Out of Network You have met $485.68 of your $1,500.00 deductible

Note: The Deductible is the amount you must pay for certain covered health care services before BCBSF/HOI begins to pay for covered services. Please refer to your schedule of benefits for services that are subject to the deductible.

Coinsurance* In Network BCBSF pays 80%

Out of Network BCBSF pays 60%

Note: Coinsurance is a pre-established percentage of the allowed amount you are responsible for, if any, for covered services. The percentage shown above is the percentage of the allowed amount that BCBSF/HOI pays for covered services after the deductible is met, if applicable. Please refer to your schedule of benefits for services that are subject to the deductible.

Plan Maximums

Out-of-Pocket Maximum* Individual

In Network You have used $142.15 of your $2,500.00 maximum

Out of Network You have used $142.15 of your $2,500.00 maximum

Family

In Network You have used $142.15 of your $5,000.00 maximum

Out of Network You have used $142.15 of your $5,000.00 maximum

Note: The maximum you will be required to pay out of your wallet in a calendar year for covered services. This coinsurance maximum does not include any amount paid toward the deductible or any copayments and excludes pharmacy.

Sooo does this mean the most I will have to pay in the most is 2,500?

Regardless of the 20% copay? I'm very confused when it comes to insurance since i've only actually have had health insurance that i'm responsible for, for almost 2 years....loost loost, i've lost my marbles

[kaninag 35]

Which BCBS plan do you have? Do you have Empireblue or just plain BCBS?

My insurance was 80/20 as well and up front all I had to pay was my deduct. +500 for something but I cant remember what that was...but see my doc didnt request that I pay anything until I got approved!

Insurance co. pay a discounted amount to hosp and such bc they have contracts with them. So, lets say its a 30000 surgey (this is what mine costs) your 20% would be a lot (6K) but the insurance co. says nope we pay the hosp. (BC we have a contract) 4000 for the surgery so your 20% would be 400. I think all together I have paid about 1100...and alot of that was paid after the surgery. Good luck to you...I just dont want to see you shell out 5k unless its absolutely necessary......:cool:

[dwrd73 0]

You need to know what your insurance requires when it comes to BMI before you try and get it approved. Because if you do not have the required BMI you will most likely not be approved. The good news is most insurance companies what to see a BMI of 40 with or with out comorbs. or a BMI of at least 35 with one or two comorbs. I doubt back pain will count as a comorb. If your insurance is similar to what I just mentioned then go out there and enjoy some of your favorite foods for the last time, wear some heavier clothes and then get weighed in with a BMI of at least 40. Also, don't stand up as straight as you can when you get measured. You will be amazed at how much your BMI changes by just half and inch.

I was in the same situation. When I submitted my paperwork my BMI was 34.8 and I have hypertension. The one nurse canceled my appointment because I did not have the required 35 BMI and two comorbs. However, my insurance only needs one comorb. I did everything I mentioned above, plus I ate a meal and drank a bunch of Water just before my appointment. I was several pounds heavier and had a BMI of 35.6. I was the first time in my life I was glad I gained weight.:cool:

I don't feel bad about eating up for the lap band b/c once I'm approved (I should hear any day now) I will save thousands of dollars. Plus when I went to my first informational meeting the doctor presenting really did not agree with the insurance companies BMI requirements but understood that they needed some sort of system so they wouldn't have to pay for everyone. He also mentioned that they are seeing great results on patients with low BMI's between 30 - 35.

[lafrogura 0]

Use an in-network doctor and in-network hospital and the most you have to pay is the $2500, minus the 142.15 you've already met. Your doctor and the hospital can charge you above and beyond what your insurance "allows" if they are not on your insurance plan network. Out of network you will pay 40% plus the difference between what the hospital/doc charges and the amount your insurance allows. In-network you will pay only 20% of what the insurance allows. No more. So if you go to an out-of-net doc/hospital, they might charge $30,000 to your insurance, but your insurance might say only $5000 is allowed. So the rest will be billed to you. Not a very good route to go since you have a PPO. Make use of your insurance and use your PPO benefits. You pay to have that benefit so you aren't charged an arm and a leg. that's how you keep your cost down. If you do choose an out-of-net doc/hospital, then make them cut you a deal. They can do that since they aren't contracted with your insurance. They don't have to collect your deductible, etc. The hospital i work for, honors patient's in-network benefits if we are not on their ppo plan. That means, we only charge them the co-insurance (20%) and do not collect their deductibles. We write them off completely. There are a lot of hospitals out there doing that and the doc should do it, too. Let me know how it goes. Also, for your out-of-pocket max, you can apply for Care Credit. It is a health expense credit card. If you pay it off in a year, there is no interest. You can apply at www.carecredit.com ... Just make sure the facility accepts it. Most of them do. Or you can go through capital one.. they finance a lot of healthcare for very low interest rates. If you want more info, let me know.

[dolly_lala 0]

kaninag- i have bcbs state employee ppo plan through my husbands job with the dept. of corrections...

So...from what you guys are saying if i go in network, the most i will have to pay at all is 2500...assuming right?