Talk to me about TriCare + Comorbidities

radar626 · September 13, 2008

I have billed Tricare for ten years and it's also my insurance. Rule #1 with Tricare - YOU WILL NEVER GET A STRAIGHT ANSWER. Every time you speak to someone the answer will be different. My surgery paperwork was actually handled on base by one of the nurses whose job includes filing the packets for banding or bypass surgery. I actually had more problems getting the approval for spinal fusion surgery with three different doctors stating I needed the surgery right away. That took six months. The approval for the lap-band surgery? It was less than two months from the date of initial request to my surgery date (which was postponed - due to back problems.. ha ha on me..) I was shocked. Rule #2 - don't accept the answer from your doctor "what's done is done". Bull crap. It takes two minutes to call and amend your packet. Doctors do it all the time.

First up, did you go through a MTF or a private doctor? MTF is ten times faster than a private physician request. Next, did you make a list of all the diets you have tried over the last ten years? Even though Tricare doesn't request this, it helps. There is no time requirement for co-morbid symptoms. And don't let the wording fool you. If you have an immediate family member with any of these symptoms, tell you doctor to make sure they include that in the packet to Tricare! Having an immediate risk for these symptoms also supports your need for surgery. Ask your doctor if you are "pre" for any of the listed morbidities. Pre-diabetic, pre-hypertensive, etc. This all counts towards the co-morbidity symptoms. It's not the wording that the doc uses, it the coding. The diagnosis codes your doctor assigns to you is part of what helps determine if you get the surgery. "Pre" conditions are part of that code set. If you are just barely in the normal for sugar, you could be considered pre-diabetic. Also, find out in what order the doctor listed your diagnositic codes in. If the most severe was not in spot #1, your request can be denied.

It's all paperwork to the insurance companies - not real people. The fact that Tricare covers the lap-band surgery since 2007 was not in print until early 2008 - remember that. Some of the people who review your packet may not have the best or most current info. Make friends with the consult office on the closest base to you. They are the best people to push this through. If you have any questions, please feel free to email me at jokersjunk@yahoo.com Just don't let them tell you no!!!

Edited September 13, 2008 by radar626

tomatogirl · September 14, 2008

Thank you so so so so so so much, radar. I'm going through a private doctor and I should hear back this week. Fingers crossed, but I'm not counting on it.

Maggies · September 15, 2008

radar, that was a lot of good information you gave all us Tricare folks. Thanks so much. :lol: Tomato girl, I hope to hear something this week to on a date for banding, and like you an APPROVAL from Tricare. I will be out of town until Wed. nite and then have an appt. with the surgeon on Friday. Hopefully we will all get approvals and be banded in early Oct.:cursing: Talk more later this week. Good Luck Maggie:shades_smile:

radar626 · September 15, 2008

Always willing to help others "beat" the system, and Tricare can be one of the worst! Be careful though when you actually get approved and go through all of the paperwork with the surgeon.. Tricare isn't a huge reimburser, and doctors that see a lot of Tricare patients often use many non-covered codes in order to give services. If you don't sign the noncoverage waiver, you can't have that particular service, and therefore no surgery, so they have you between a rock and a hard place. It isn't against the rules (yet, according to our local Tricare rep), but for things like the nutrional consult, anything done in a group setting (like education or seminars) or even educational materials, these things aren't covered. Be careful and ask for a full list of out of pocket expenses up front. It may delay your surgery by a week or two, but if the surgeon they send you to tries to make you pay out of pocket or up front, call another Tricare approved surgeon and switch! I did this, and am glad I did. Whole big mess, but the orginal surgeon I was referred to is no longer in the network because of questionable practices. Some people will do anything for a buck.

If anyone ever has any questions about their bill, let me know! :tt1: