Where do I start?

[JayinMA 1]

Hi, i'm sorry, I should probably know this, but where do I start with all this? I have decided the Lap Band is the way I want to go about losing weight and I started my new job recently and my insurance just kicked in. I contacted member services about the procedure and this is what they wrote back to me:

Thank you for your inquiry via the Harvard Pilgrim Health Care (HPHC) Secure Website regarding your coverage for bariatric surgeries such as the lap-band procedure. I would like to provide you with the following information.

Bariatric surgeries are surgical procedures that are intended to assist morbidly obese patients in achieving medically significant long-term weight loss.

Harvard Pilgrim covers bariatric surgeries that are Medically Necessary for morbidly obese members with documented history of failure to lose weight despite physician-supervised medical/dietary therapies. The following services are covered when specific medical necessity criteria are met.

• Gastric Bypass (Roux-en-Y)

• Gastric Stapling

• Vertical Banded Gastroplasty (VBG)

• Laparoscopic adjustable silicone gastric banding (Lap Band)

• Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS)

Comprehensive multi-disciplinary program including:

• Pre-operative medical and behavioral health evaluation

• Medically necessary surgery

• Post-operative follow-up including nutritional and exercise counseling

Prior authorization is required for all bariatric surgeries. Clinical information must be reviewed by HPHC before services are authorized. Your physician will need to contact HPHC to begin the authorization process and provide our Medical Management Unit with all of your clinical criteria so that it may be reviewed for Medical Necessity.

If services are approved, per your schedule of benefits, member responsibility for Inpatient and Day Surgery services when performed at a facility recognized by Harvard Pilgrim as a Weight Loss Surgery Center of Excellence would be subject to a $300.00 copayment per admission when using a Participating Provider.

Services must be performed at facility recognized by Harvard Pilgrim as a Weight Loss Surgery Center of Excellence in order to be covered. The following is a list of facilities recognized by HPHC as a Weight Loss Surgery Center of Excellence:

Massachusetts

• Baystate Medical Center

• Berkshire Medical Center

• Beth Israel Deaconess Medical Center (BIDMC)

• Brigham and Women’s Hospital

• Boston Medical Center

• Caritas Norwood

• Caritas St. Elizabeth’s Medical Center

• Emerson Hospital

• Faulkner Hospital

• Lahey Clinic Medical Center

• Lawrence Memorial Hospital

• Lowell General Hospital

• Massachusetts General Hospital

• Mercy Hospital

• Newton Wellesley Hospital

• North Shore Medical Center – Salem Hospital

• Southcoast Hospital Group – Tobey Hospital

• Tufts – New England Medical Center

• U Mass Medical Center

• Winchester Hospital

Maine

• Eastern Maine Medical Center

• Maine Medical Center

Rhode Island

• Roger Williams Medical Center

New Hampshire

• Portsmouth Regional Hospital

Please note coverage for services is based on the patient’s eligibility and plan provisions in effect at the time services are rendered.

Ok so that all sounds good, but now what? I don't have a primary care physician because I have a PPO instead of an HMO and I'm just confused as to what my next step is.

Any help you can offer would be greatly appreciated.

[Tess415 1]

I have a PPO and have a family doctor that I have seen yearly, and for illnesses... Are you saying you don't have a medical doctor that you see?

If you don't have a family doctor or an internist I think you should get one and get a physical.

Next, you need to find a surgeon on your plan that does the surgery at a facility that is on your list. They should be of value in helping you through the red tape of insurance...my surgeon's office knew what was required and its just a matter of hoping thru the hoops. If they have a free seminar go to it and get information from them.

The good news is you have coverage, now you just need to follow the steps!

Edited September 25, 2008 by Tess415

[JayinMA 1]

Yes you are correct I don't have a doctor. I just recently got insurance after five years of being a "contract" employee which meant I didn't have to paid benefits and so I wasn't.

[Tess415 1]

Ask around and find yourself a good family doctor or an internist. Get a good workup including labwork. You may have issues you don't know about... borderline diabetes, thyroid problems, high blood pressure. Anything like this would be important to document for your insurance to prove medical necessity.

My surgeon's office does so many of these that they know their way through the hoops, and that helped me to focus on my part to get done to get approved!!

Good luck!!! It can be done, be patient and persistent, take lots of notes of who tells you what, and keep a folder with all of the information you get to keep yourself organized.:confused:

[JayinMA 1]

Thank you so much for all your help! I have a BMI of 46 and I think i'm going to have a sleep apnea study done. I will look into getting a "usual" doctor and I think i'm going to sign up for an info session

[Mr. Green 3]

After attending an info session I came out much more educated about the all the stuff that needs done before you even get a surgery date. The nice thing about the group that I am going with is that they know what is required for your insurance carrier and I am sure most groups know this.