Medicare Is Confusing Need Help

[Kharadriisa 0]

Ok new here. Got a call yesterday about my referral to a surgeon. Have medicare and tenncare. They had to get credited or something. Was told that since my BMI was 42 that I wouldn't need a co morbidity. Called Medicare today to make sure.

Medicare said I would have to have a obesity related illness. Was told High BP or diabetes. Asked if there was any others. Said no. Was she right? She was just reading from a list. And didn't spend much time looking into it :/ Really wanna know if others understand the process more.

Thanks in advance!

[txwanab 0]

Medicare will cover it. They typically want you to go to an approved facility, Centers of Excellence. So make sure you look up that on wherever you go. Not all docs take Medicare. Make sure you find out your deductible too. Some docs try to get people to pay them more than they are supposed to. For example they will tell you they have a package deal. No way. Your insurance will pay for dietician and all other BS. They just want $. I have known of others who had arthritis, type 2 diabetes, sleep apnea and many other things getting Medicare approval. Dont give up. The surgeon should fight it for you. Dont be surprised if you are asked to undergo lots of testing. You probably will not be able to go to an outpatient surgery center. So make sure the hospital has a good follow up program, like support groups and band adjustments. Also find out how long your doc has been doing the band or whatever your having one and how involved are they with general surgery. Dont want some slacker cuttin on ya. You want that doc who will save you if something "funny" happens.

Best wishes.

[Kharadriisa 0]

Yeah they just got approved as a center of excellence. That's why they called me. Just not sure about what all the other illnesses are that's related to obesity. They would only mention 2. I'm sure there has to be more :/

I've had high BP before. My first child I had preclampsia -spelling-. The high BP didn't go away after she was born. Had to take meds for months afterward. It finally went down. If I use any salt at all my BP raises. Had a doctor fuss at me for it. And I only use salt in rare circumstances.

[Kharadriisa 0]

Why does this have to be so hard I called again today after the center told me that I should be covered. Well the girl on the telephone talked to her supervisor and said as long as the doctor believes I will be approved and files a claim they will pay for it. That's the funky answer, but it works for me :sad_smile: Anyone else have any concrete proof? I know i'm a skeptic, but when it comes to that much money if it's not approved I can't take a chance.

[JoannMarie 0]

Why does this have to be so hard :biggrin: I called again today after the center told me that I should be covered. Well the girl on the telephone talked to her supervisor and said as long as the doctor believes I will be approved and files a claim they will pay for it. That's the funky answer, but it works for me :wub: Anyone else have any concrete proof? I know i'm a skeptic, but when it comes to that much money if it's not approved I can't take a chance.

Hi Kharadriisa,

I have a couple of questions for you. Are you on Medicare because of a disability - and if so, does that disability have anything to do with morbid obesity? (this might be the co-morbidity the surgeon's office says you need) However, the Medicare rules on the their own website state that if you have a BMI over 40 you are eligible. Under 40, you would have to have co-morbidities, such as high BP, heart disease, diabetes, arthritis, and I believe some others. If your BMI is 42, it sounds to me like you should be covered. Consider calling back and asking to speak with the supervisor about your specific case.

My surgeon's office had me go through all the testing, paperwork, psych evaluation, nutritionist, sleep study (for over 65), etc., etc. The coordinator told me they follow every recommendation and guideline Medicare requires, then submit a letter on my behalf. I was unclear whether or not they actually receive an official "approval" from Medicare, but she said if they have followed all the guidelines Medicare will pay. I have had my consultation and been given a date for surgery, so apparently the word is go.

I went out to the Medicare website and read what I could find. It seemed pretty cut and dried to me, but I know government-speak can have different interpretations depending on who is interpreting. (that's what worries me about gov-run healthcare!) Check out the MC website and "arm" yourself with whatever information you can get on your own, then talk to the supervisor.

Good luck!

[martucci 0]

Hi, I was told this surgeon I went to isn't taking medicare anymore because they aren't paying for the fills for people. Is this true?

Thanks, Karen

[terilynn112 1]

They pay for fills.

They also don't give much issue with comorbities if you're over 40 BMI. I was/am. I had mine a month ago. They don't require a pre-approval, although your secondary insurance may. As soon as I met my center of excellence requirements, they scheduled my surgery. Almost a month later, but that's ok. Gave me time to get things in order. I've gotten not one bill, and I've been there a couple times, for a minor skin infection.

Medicare is actually one of the easiest to deal with insurance companies I hear.

teri ( on medicare because of a disability)

[JoannMarie 0]

Thanks Terilynn. I feel better every time I read of successful surgery with Medicare. I have not heard anything from an actual post-surgery patient that would lead me to believe there might be a problem with Medicare coverage. That's encouraging! Also good to hear they pay for fills - the one question I had forgotten to ask... duh.

I love your picture - what a great little family. I bet they keep you just a little busy.

[martucci 0]

Teri, Are you telling me Medicare pays your fills? That would be great news as the dr. said they don't. I will wait for your answer. Thanks.

Karen

[Kharadriisa 0]

I am on it for depression and anxiety related. My doctor doesn't take medicaid and i have both. it's a crossover where medicaid pays what medicare doesn't so no co pays unless it's a prescription. It's a pain since they are making me pay co pays even though i'm not suppose to. Gotta call and talk to someone else to figure it out.

[Kharadriisa 0]

I am getting the run around. Called the number I was told to and they said they can't do anything that i have to call the number that i called the first time that told me to call them. Tried calling no one is answering even though they are open :/

Went to a seminar last night and man it was bleah. The woman beside of me kept falling asleep and snoring. I'm the type of person that laughs at the stupidest things and I had to control myself :biggrin: I think i'd croak if i laughed :/ Gotta goto a group session tonight. Only get a chance once a month. Learned last night that we have to go through 6 hours of education before we can have the surgery. 1 down another 5 to go. Got my consult with surgeion nov 7th. Gotta pay 150 +40 co pay. Bleah gonna be hard when my disability is only 700$ a month and I have 2 kids.

[terilynn112 1]

I get 701 dollars a month, and have 3 kids. So I do understand, and am a single mom. No support from bios.

They pay for my fills (so I'm told. I haven't had one yet).

I asked my surgeon's office, and I asked the medicare rep I talked to, and they said they cover all related care. So that means fills.

teri

[JoannMarie 0]

Good luck to both of you. I don't know how you manage to raise your families on that amount of money. DH and I raised 3 kids with his income and I know how tough it can be, but there were 2 of us. You gals are seriously out-numbered! You have my admiration and my prayers.

[Kharadriisa 0]

ugh just now getting back into this whole mess. Didn't realize how sick I was last week. Went to doctor Friday and found out i had walking pneumonia. Been going to seminar and group thing for this who knows how many peeps I infected. Feeling better finally and now faced with getting kids to their doctors this week and next and two halloween parties at their pre school. Phew. I can't wait to lose this weight so that I can be more comfortable while doing all this.

Gotta consult appointment Nov 7th. So gotta raise 190$ total to cover the co pay and remedy MD thing they require. If they take Care credit for co pays then I can deal.

[terilynn112 1]

I hope you're feeling better. It's hard concentrating on anything when you are that sick.

Teri