I don't know if I have all my ducks in a row???

[Mommy07 0]

I attended the free seminar and a support group on 08/13/08. I mailed in my application for the surgery on the 14th. I also went to see my PCP on the 14th and got referrals for all the doctors I will have to see for the surgery. However, I haven't been "approved" by the surgeon's office yet for the surgery. My insurance company doesn't require me to do anything. Their only requirements are; 100 overweight, 35 BMI with co-morbidities, 40+ BMI, no smoking, over 18 yrs old and under 60, and the hospital has to be a "hospital of excellence". I have Harvard Pilgrim Health POS they will pay for everything as long as I have a referral from my PCP. I only have to pay for doctors co-pays =$20

So, I went online to see what the surgeon requires:

Insurance Coverage

Because many insurers consider weight loss surgical procedures elective, patients must obtain insurance approval *DOES THIS MEAN A REFERALL FROM MY PCP?* for the surgery prior to scheduling the procedure. There is no fee for the information session. While many of the costs that will be incurred during the evaluation process will be covered by insurance, some charges may become the responsibility of the patient.

If a patient qualifies medically for surgery, the surgeon’s office will request pre-approval for coverage of the procedure from the patient’s health insurer *ISN'T THIS THE SAME THING AS ABOVE?*. When the insurance company gives its pre-authorization, patients are notified by the surgeon’s office. In most cases, a date for the operation will be scheduled during this notification. For patients not covered by insurance, there are self-pay options that may be discussed with accounting department. Once a date for the operation is scheduled, patients are often asked to come into the office about a week before the procedure. If patients are not eligible for surgery or decide it is not an appropriate option for them, SMMC is committed to helping them attain their weight loss and health goals. Other weight management and exercise programs offered as part of our Weight management program are also available. Ask the program coordinator for more information about these options.

Steps to Take - Surgery

• Attend the Information session. (MANDATORY) *CHECK-I DID THIS*
  
  • Educational/Informational sessions occur at 6pm for new patients admitted to the program. Patients wanting information only on the Gastric Bypass Program are welcome to attend.
    
  • Attend a minimum of two Gastric Bypass Support Groups prior to surgery.
    
  • *I AM ATTENDING THE SECOND ONE ON 09/10/08*
    
  • Complete packet questionnaire and forms. (The packet is handed out at the information session).
    
  • A medical release is included in the packet in order for the team to obtain health information from your primary care physician. Please sign this release and include it with your application.
    
  • Mail in the packet to the address provided
    

So, what do I do now? Can I even get a referral from my PCP for my insurance company before I know that I am approved by the surgeon for the surgery?

[Emily'sDad 0]

It sounds as though the hang up is at your surgeon's office? If so then give them a call to see what is going on. If it is your insurance, there is nothing wrong with calling them to see what is happening.

In my case some of my paper work got fouled up. By calling I was able to straighten it out without too much trouble.

good luck!