Diana S.
Hi. I am a 23 year old girl, living in Penn Valley, CA. I have been overweight all my life, but until I moved in with my last boyfriend, it had been manageable. My bf made life absolutely unbearable, and to compensate, I soothed my hurts with food. I got myself out of that finally, but at a staggering 340 pounds. I felt like I was dying. I felt like I didn't have a shot at a normal life anymore, and that I shouldn't even hope for what was beyond reach. I began to see articles about Gastric-Bypass, and how it had changed lives, and ruined them, and thought that people would have to be really desparate to do something so risky. I decided to give it a fair look, however, and found some hope afterall.
I have been researching Lap-RNY for over a year now, and have run into all sorts of dead ends, including different insurances and their barriers, choosing a new surgeon because the one I REALLY wanted isn't covered, has a huge waiting list or whatever, and various other problems.
Today is August 17, 2005 and I finally have resolved to pay for this myself, and am awaiting my consultation on the 26th.
It has been a long, frustrating journey to get to this point, and before I signed up for ObesityHelp.com, I had my LiveJournal. Here are the excerpts from that, documenting my progress (such as it was).
August 25, 2004
Well, I'll be all set up with my benefits from work soon. I turned in all the paperwork for medical, dental, vision and life insurance today. They kick in Sept. 1st and I am more than anxious to see if and how much of my surgery they will cover.
I've tried to scour the web to look for my particular insurer in regards to WLS (Weight Loss Surgery) coverage and I get back encouraging and discouraging info. I hope this goes smoothly, but it seems nothing worth having is easy to get.
September 16, 2004
Well, my benefits are activated, and I'm wasting no time. I called the other day to get an appointment to meet with a doctor on October 13th. In this meeting I will tell him my goals about the WLS I desire/need. I hope he will be on board with me. If not, I'll find a new PCP (Primary Care Physician).
Today I called my insurance carrier (Great West PPO) to get the prerequisites for approval of this WLS and Debbie from Customer Service (typing this in here for my future reference... god knows I won't remember, and I'll lose the sticky I wrote it down on!) said that I need:
*to be a BMI (body mass index) of greater than or equal to 39
*pre-authorized before I go off and have this surgery
*need my doctor to call in with my medical stats/history/certification
This is step one.
If I meet all these criteria, then I can move forward. Next, I asked Debbie-from-Customer-Service what my coverage would be.
If I chose an In-Plan doctor (which of course Dr. Rutledge from CLOS.net isn't) it would be covered 100% plus a $250 in hospital co-pay.
If I chose and Out-of-Network doctor, then my coverage reduces to 70%, plus a $250 in hospital co-pay, and a $500 deductible.
Of course I'd rather pay zero, but there's no such thing as a free lunch. (haha, interesting pun)
So for a $17,000 elective surgery, I'll wind up paying just under $6,000. That's $5,100 as my 30%, and the $250 and $500 co-pay and deductible.
I don't know about you, but $6,000 is pretty cheap for a new lease on life. I can't wait for the dance.
September 22, 2004
I sent in a request to my health insurance company to list in writing the requirements of wls coverage. I didn't expect such a freakin' fuzzy answer, but I'm not that surprised, I guess. They basically said, "We'll see. Have your doctor call us." Grr...
Meanwhile, I wrote to CLOS.net (Specializing in the Mini-Gastric Bypass = MGB) and asked of they would add themselves to the list of covered doctors on my insurance. I got a reply saying that they'll look in to it, and a ":)" I am really beginning to love the customer care there! Hopefully that will be good news.... ihopeihopeihope!
October 19, 2004
I finally, finally saw my doctor last Wednesday, and he was totally on board for wls... the only thing is there might be a problem with "who gets chosen for me." I told him that I had my heart set on Dr. R and CLOS and he said, "Well, on a PPO you might be able to choose." I had freakin' better be able to choose! He also set me up for some blood-work to test for a bunch of weight related problems, and he is setting me up with another doctor for a sleep test.
October 25, 2004
I called my insurance company again. This time I spoke to Renee, Customer Service Rep, and told her that I wanted a faxed copy of all the requirements. She gave me some bullsh!t answer about how she could only tell me some things verbally (so like they can't be held to what they say?) and otherwise, my doctor must contact them.
I've written a long letter to my PCP asking him to help me, and please read the MGB manual, go to the MGB site, and work with my insurance company, please please please! I'm going to drop this all off today, and hope like hell this guy isn't a flake. I need SOMETHING to go smoothly!
Also I FINALLY heard back about Dr. R being added to my insurance so I'm covered 100% instead of 70%. Basically, there's no way to add him for some reason that I don't understand, and that makes it sound like it's not their fault. *sigh* Nothing worth having is easy to obtain, I guess.
Also... I was wondering if maybe Medi-cal or Medic-aid could help me out... I think I'll swing by their offices.
October 26, 2004
Well, I decided that there's no way in hell I want to take on a $6,000 loan for the difference in insurance coverages, and that I really don't want to travel eight hours each way to Los Angeles to have my surgery done.
I looked on my insurance medical directory and on Google concurrently to see if there was a reputable wls center that was covered by my insurance. I found one that didn't make me raise an eyebrow, and halleluiah, I think it's covered.
It's in San Francisco and it's the Laparoscopic Associates of San Francisco.
They have a VERY similar procedure to the MGB, and I feel better about it the more I read the site. I've submitted all my patient info that I can online, and I've requested an appointment for early November... I wonder if THIS will go better.
November 4, 2004
The new place in SF that I made an appointment with won't work. I thought they were covered under my insurance, but only the hospital where they practice is. I called my insurance again and this time got a HELPFUL PERSON! OMG!! Her name was Jamie and she was actually upfront and honest with me. We talked a bit about what Great West would cover if I went to the SF place, and it would be even less than I originally thought.
An out-of-network surgeon would cost me $500 deductible (knew that), a $250 something fee (knew that), and 30% of what is usual and customary pricing for this procedure.
I asked Jamie what they considered usual and customary, and she said that, "You probably won't ever get a straight answer on that one." While the answer was irritating, the honesty was refreshing. I had had a previous conversation with the SF place (Amy) and she said that if there were no in-network surgeons that my insurance would have to cover out-of-network costs. I brought this up with Jamie at Great West, and she said that there must be someone, so she looked up a whole bunch of names, numbers, recommendations, where they graduated, etc. etc. I chose a new hospital/program/thing, and it's with UC Davis... I know I said I didn't get the right feeling from them, but upon a second inspection I think my opinions were incredibly biased.
I called my PCP and he sent off a referral either last Friday the 29th or this last Monday the 1st. I called my PCP's office on Tuesday to follow up and the lady there said that it takes x amount of days for UC Davis to get their stuff together, blah blah blah, so I should hear from them in a few days.
November 16, 2004
I've done a lot of calling back and forth to see if my referral was ever received. On November 9th, I called the UC Davis Medical Center (again) and while the main lady, Elizabeth, was out sick, the filler-inner person verified that they got my referral FINALLY that day at 9:40am. Apparently the next step is waiting for Elizabeth to send me a packet of paperwork in the mail for me to fill out and send back to them pronto.
So I'm waiting... and waiting... and I get a package in the mail. However, when I opened it, it isn't what I expected.
"Guess what? We're changing your benefits! Yea!"
Great! Now instead of a $0 deductible and 100% coverage, I'll have a $150 deductible and 90% coverage for my surgery... and I may even fit under the pre-existing conditions clause, which will deny me coverage on this for six months or so... yipee!
There was also something that said that if I were already in the middle of treatment, that I could continue my treatment at the same level of my previous benefit carrier (temporarily). Perhaps if everything can get going, I could slip in under that.
I have until January 1, 2005 to get as much done as possible, even though I am constantly waiting on various other people and hospitals. >:(
November 24, 2004
So I have to change my insurance to Cigna HMO. It's going up in price, and in addition, they won't cover any kind of WLS in 2005. My only chance now is to get these damn forms to me and filled out... get the process moving so I am as close to operated on as possible. That way I may fall under their rider plan, which says that any treatment I was in the middle of, they will continue at my previous plans perameters. Honestly, I don't think this will happen.
December 20, 2004
I got into a horrible car accident (where I broke my femur, patella, fiula and tibia) on this day, so thoughts of WLS were put off until...
February 21, 2005
I just recently found out that I'm covered under my father's Blue Shield HMO insurance (and have been since he took that job a million years ago). They apparently cover WLS, so the game is back on. My PCP wanted a "feminine exam" done... so I gritted my teeth and made it through alive! When the test results come back (not expecting any suprises), I'll find out what the next step is. Also, my Blue Shield coverage ends on my upcoming b-day, but fortunately my dad can have it extended due to my "physical disability."
March 15, 2005
This coming Friday, I have an appointment with my PCP to get all the preliminary crap out of the way. I need all these tests to make sure I don't die on my surgeon. On April 1st I have a consultation with the actual surgeon who will perform the surgery and I hope things will progress swiftly from there, as my father's health plan won't extend my coverage as I had hoped.
Meanwhile...
Before my consultation with UC Davis, Elizabeth had called me, and in the course of this conversation, she said something about my Great West coverage. I said, oh no... it's Cigna now. She said that they didn't even contract with Cigna, so oops... brick wall. I was having enough trouble getting my hospital bills from my car accident paid that thoughts of WLS were back-burnered. Then, after my b-day and I was offically off my father's plan, I got COBRA information. With no job, I was unable to afford the COBRA payments, but I finally got the settlement from the accident, and said, "Hell with it! I'LL pay!!"
July 31, 2005
I signed up for the COBRA that was offered to me when I fell off my dad's insurance plan, and can look forward to much needed dentistry (e.g. wisdom tooth extraction, among other things), another look at my healing progress, and maybe some hope in the WLS department. We shall see.
August 17, 2005
After this, I find that COBRA no longer has me in their database, so no COBRA for me, eventhough I was within the time period to sign up for it. The lady that handles this is trying her best to push me through somehow, because it was her fault about the time discrepency. I am waiting for a yea or nea still, but honestly I'm not holding my breath on the Blue Shield HMO front.
I have enough left of my settlement to pay for this myself, and have contacted the Laparoscopic Associates of San Francisco again. They have a self-pay amount for the Lap-RNY of $23,900, plus a $375 consultation fee. I really like the people I've spoken to thus far, and they even come to Sacramento for the consultations and surgery (maybe I won't have to stay in a hotel!). I hope for a more pleasant ride from here on out.
My consultation is with Dr. Feng and is scheduled for the 26th. I expect to update regularly now. Wish me luck!
November 12, 2005
I had a momentary blip in time where I thought insurance might cover this afterall. I unexpectedly got some Blue Shield HMO Cobra cards in the mail, along with a bill of course. I thought, "Great! Somebody up there likes me!" but they will only cover UC San Francisco, not LAPSF or any of my second and third choice places. UCSF also wants a heck of a lot more tests run, and they say, if I'm REALLY diligent, I MIGHT get a surgery date within the YEAR.
This is no good for me, so I wrote an appeal letter and if it works, great, if not then I'm still Self-Pay. I called LAPSF and told them I was ready! I have a surgery date set for December the 14th, 2005. Merry Christmas to me!!
This way I have a couple weeks to heal and get used to a new way of life, before I move to Berkeley and start attending college there. I'm really anxious, excited, scared and expectant. I can't wait or believe it!
About Me
Before & After
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