Frustrated and barely started....(Long)

Longtime Lurker, SECOND time poster and I have made the decision to do VSG, I posted in another message that I am 33 years old, 5'4 and about 340lbs. I have been considering WLS for about 8 years and started seriously reading these boards (mostly the insurance denials part) for about two years. The wonderful people here recommended I consider either the DS or the VSG. I started reading these boards night and day and cam more confused than ever. It seems like the bariatric center I have chosen is not giving me the information I need. I am reading about all sorts of things on these boards that were never mentioned by the center.

 I attended an infomation session on October 20th 2010 (BMI Center Joliet) and got a call from them the next day saying I was approved through insurance (BCBS IL PPO)  for surgery. The person that called did not specify what type of surgery my insurance would approve, and did not have any information concerning out of pocket expenses or deductibles. I tried to ask her about gathering medical records. She stammered and basically said for me to wait until I meet with the surgeon (November 3rd 2010.) I realize patience will be an integral part of this process, but I am at a loss as to why I should let 2 weeks pass doing nothing when I could be getting medical records, signing up for the supervised weight loss plans etc. So my first question is should I go ahead and do these things to get the ball rolling? My next question is what exactly is an approval? I realize that there will be a FINAL approval much closer to surgery, but does hospital calling the insurance constitute an approval?
 
I highly doubt that my consult with the surgeon will involve an in depth discussion of my insurance coverag,e out of pocket and deductibles. Who can I speak to that will be able to accurately provide this info? The insurance company? The hospital? Again, I am all for patience, but I just feel that the wait for the surgical consult is kinda....used car salesman ish. Either my insurance will cover this or it won't. No need to have me come in, get lectured on how much the surgery would improve my life, then be hit with an estimated 5 or 6 or 7k out of pocket expense. A general idea of percentages, of what is covered will be helpful. I am a stay at home mom so everywhere we go is a huge production with strollers carseats and etc. If I need to have some sort of in depth exam, I need to get a sitter, etc. The hospital is providing NO information other than to show up at a certain time to meet with the surgeon. Can someone shed some light on what to expect? If I am simply going to be weighed and basically converse with the surgeon. Fine. If I am going to be getting undressed and having an in depth exam etc I need a sitter. I am frustrated because I feel I am getting the runaround already. I can imagine what lies ahead if they don't get their act together. Has anyone else gone through this center? Can anyone give me a generic idea of things I COULD be doing? Who has the better information concerning insurance coverage, the hospital or the 1-800 number people listed on my card? Anyone have any experience with this doctor/BMI center?

edit to give credit where due

I attended that same program at BMI Surgery at Silver Cross Hospital about a year ago with a friend.  Their protocol must have changed a bit.  The first step upon entering the conference room and registering was to present my insurance card so the office staff could make a copy.  Then the presentation continued with Dr Joyce.  Kind of weird, they brought a patient into the room in a wheelchair that was being discharged after having Lap-band.  The patient told us all how wonderful she felt and how she has not had to take any of her diabetes medication since surgery.  I thought it was unusual ,to say the least, to put a patient on display, but she must have given her approval beforehand.  I didn't think she looked so great....that must have been the pain meds talking.

The next day my friend received a call telling her insurance (BCBS) "covered"  WLS, not that it was "approved", she would have to go through all the usual pre-op testing...sleep study, blood tests, meeting a psychiatrist, xray, etc, then BMI Surgery would submit to insurance for "approval".

Sadly, I was told BMI Surgery does not accept my insurance (United), but of course would be happy to work with me if I wanted to self-pay.  Uh....big no thanks to that. 

Anyways, sorry for the bit of a rant.  Lucky you if were approved on the spot.  It certainly would not hurt to get previous medical records to bring on the day of consultation with the surgeon.  Also, would not be a bad idea to simply call your insurance company and ask.  Never hurts to ask.

I TOTALLY get the need for a rant when dealing with this. I read your post and your second to the last paragraph is kinda of what I am getting at. They seem like they are ready, willing and able to start a heavy duty sales pitch on self pay and financing options. And while reading this board, I am now aware of just how many people chose to self pay. So its not all THAT uncommon, I guess my issue is that it seems like they have no problems delaying bad news, or still having people show up in their office just to turn them down, or tell them their out of pocket expenses will be astronomical BUT there is always self pay/financiing etc. Make no mistake, it was only mentioned briefly in the informational session, so I am not trying to imply any seediness on their part. It just seems like they may be accomstomed to patients who want it so bad that they (THE FACILITY) can sorta do whatever they want in the process.... Again I am nowhere near implying that there is anything seedy about the place. Just my gut talking.

First off - welcome back to the IL board. All of us welcome trying to help a newbie get their questions answered or pointed into the correct direction.

First off I am leary of an office that is telling you this fast that you are approved for "whatever" surgery. You have to fill out a questioneer as to your medical history and then meet with the surgeon before the office submits what surgery type that is being requested to be approved. The medical provider has to send a very detailed letter to your insurance provider saying why you are in need of WLS. In answer to your question about approval=NOT. It is incumbent on the patient to call the insurance provider to find out what the steps are for you to get approval for surgery and what types are approved.

Now, that being said there are a couple of posters (Carol422 & CMAGOURIK and possible others) here on the IL board that are  patients of the office that you are considering to go to. You might want to contact them to find out their opinion on your questions as to compling records before you go to your first appointment or  signing up for supervised weight loss plans, etc. Remember what I said only you can find out what you need medical records wise before your approval. Do not sign up for any plans or other appointments until after you go to your first apt. or have the info from the doctor as to their protocal and your insurance as to what paperwork/tests that you need to provide before approval. So call your insurance company and find out what you need. Get the info in writing, look at your plan booklet and get the name of the person on the phone that says what you need to be approved etc, etc. Keep good records. as to who you talk to and when.

Sorry, I know that you have waited a long time before knowing what you want to do with yourself surgery wise but you really need to go through all the processes by the way your insurance needs are before you get approval. You have waited 8 years and this is just a small, small additional time to wait. Just make sure that it you have all your T's & I's crossed and dotted to get approval from your insurance. Nothing is more frustrating than finding out that you need this or that documentation for approval.

For the record the exact approval that you need is the written letter from your insurance company that comes to you and the medical provider saying that you have met the qualifications and it is determined that weight loss surgery is your only option.

Good luck and come and join us on the daily roll call.

Thank you thank you thank you!

I should state for the record that my journey began with calling the stupid insurance company. The lady at BCBS had me go to the portion of the website for WLS PROVIDERS and read up on the requirements. There was a lot of technical speak there but in essence I was able to gather the requirments for them to pay for the surgery. It does not list (IN LAYMENS TERMS) what types of surgeries will be covered and for whom. BCBS provided me with the information for the facility I am considering. According to the woman from BCBS it is best to deal directly with the facility. So I guess I am saying that the best I can hope for from BCBS is to be directed to the website that doesn't really provide any information concernung out of pocket expenses, deductibles etc. As for the facility I just don't care for the way they do things. I guess that is the realization I am coming to. The woman that called me to inform me of my "approval" most definitely said approval. She did not say eligible or covered. Make no mistake, I do not say that to argue with posters here, but only to stress how uneasy I am with the way this place does things. The lady on the phone basically identified herself, advised me that I was approved for surgery and to complete my medical history online and CALL BACK for an appointment. Ultimately they called me back for the appointment. But she made ZERO mention of testing, evaluations, sleep studies etc. And like I stated, she kinda got tripped up when I asked about medical records and etc.

During the informational session, I did provide my name, address, height, weight and phone number with a copy of my insurance card. That much is the same, however Dr. Joyce stated that he would most likely have to leave early to perform EMERGENCY surgery in the ER. (YIKES!!!!) Anyways, he ran through a power point presentation for about 25-30 minutes and left. The sweet little women in scrubs (I'm, not sure if they were nurses, or clerical staff) were left to deal with patient questions. They did stress that they have a new system for patients to submit their medical histories and that we would be the first group to use the system. I can provide a link but bascially when I completed that information I felt it wasn't nearly as thorough as it could or should have been considering all the documentation insurance requires. They recommend that questionaire not be completed until you are "approved" for surgery. From there they schedule the initial consult which is the step I am facing in a little over a week. Anyways thanks for letting me vent. And thanks for the advice, and encouragement. For anyone considering thie place I will most definitely post updates although I am not nearlty as educated as most of the people here!!


Thanks again,

edit for clarification

EMERGENCY SURGERY does not mean that he was doing surgery on a WLS patient as many doctors that are on staff with a particular hospital are on call for surgeries that come in via the ER or from other doc recommendations. Breathe deeply now!

HI, I too am going through BMI Surgery at Silver Cross. When I attended the seminar and left a copy of my insurance card (BCBSILPPO) They also called me the following day and stated that WLS is a covered service within my benefit package. She never said it was approved, she only said it was a covered benefit. She made a appt. with Dr.Joyce for me (consultation) on Sept. 29th. On that day I was weighed and spoke with the Dr about what surgery I am seeking and what would need to be done to satisfy my PPO. The following Monday I went to a Diet and nutrition class which basically was a nurse speaking to us about what each insurance co requires for approval for WLS. Mine requires a 6 lb Dr. supervised weigh loss with in 3 months. Other insurances require 6 months to 1 year. In the next 3 months I will need to have a Psyche eval, cardiologist check and a appt with a pulmonary specialist. All which require a 50.00 copay and a 50.00 copay for every visit to the Dr. Even if it's just a weigh in. I had 1 appt with the lung specialist on Friday, another tomorrow and the a few in November. They give you a list of Dr's in the joliet area.
When I have met all require ments the Dr will send off the paperwork for approval.
Good Luck on your journey.
Any questions, feel free to ask.

Lori

Hello
 

I had my surgery at BMI.  I went to the informational meeting just like you.  But before I did any of that I called my insurance company myself talked to someone that told me what my policy covered and how much out of pocket cost I would have and where I should get my surgery (some places are considered out of network).  I then had them send it to me all in writing.   I found the closeset in network place I could have the surgery was BMI.  I got my packet read it and understood everything I would have to do to get approved and how much it would cost.  I did not depend on BMI to tell me any of that.  Funny thing was when I went to the informational meeting and presented my card to them, Cherish already knew my insurance paid for the surgery because she made a comment like "oh this is good insurance you shouldn't have any problems".  
 

My informational session was much different and didn't invlove bringing in a post op patient.  What I do love about BMI is that they handled all of the insurance for me.  But I was not approved for surgery until after I did my 6 month supervised diet, my cardio, pulmonary, and psych testing and submitted my full 5 years of medical records showing I have been over weight for at least five years.  After I finished all of that they submitted the paperwork and boom I was approved in 48 hours. 

I also liked how they educated us about our surgeries and our new diets.  They have you go to classes before and after surgery.  Not all doctors have that kind of education.  They also have awesome after care, which is very important to your sucess.  You also have full access to the cardiac gym for a year.  All and all they have a great system. 

My doctor wasn't Joyce, I have Lahmann and he has a great bedside manner.  He is very kind and when I wasn't doing very well at first he was really good at making me feel better.  Now Cherish is very good at her job but she can be a bit snippy sometimes.  But I don't mind because she is very good at her job.  If you have any questions at all you can email her and she emails you back within 48 hours.  I had a list of about 12 questions and she got back to me on every question. 

My initial meeting with the surgeon wasn't much because I did all my homework and knew what surgery I wanted.  The intial appointment seems to be about talking to you one on one and helping you decide what surgery you want and what's best for you.  Since I knew that I pretty much just heard about the different bands and got to hear about them.  We did not talk about insurance at all. 

I know most of your worries are about your insurance.  Call your insurance yourself and have them send you everything in writing.  that is very important because some people can give you the wrong answers.  I will tell you my insurance covered everything surgery, testing, and office visits.  I had to pay My $50 co-pay every visit.  My final bill for everything was around $800, which I paid in payments.

Good luck

 
 

 

Hi there,

I, too went through Dr. Joyce at BMI.  I pretty much agree 100 % with everything that Crystal has posted.  I am a Human Resource Manager, and I will tell you that the Dr.'s office is not aware, normally, or responsible for telling patients about what their plan deductibles, out of pockets, co-pays, etc are.  They do take the responsibility of contacting the insurance company to see if weight loss surgery of any kind is paid for by the insurance.  Whether or not wt loss surgery is covered by your insurance is determined by what plan the EMPLOYER selects.  Most insurances cover it, but, it really depends on whether or not the employer has this option in their plan.

Crystal is right when she says call your insurance company yourself.  Ask them the questions about what your particular financial obligations would be under YOUR plan.  My plan had a $2000 deductible and a $1500 out of pocket, where Crystal's only had $500.  Again, it is your employer that decides how much those costs to its employees will be.  The Dr.s office has no choice, and prbly no idea what each patient's cost would be.  That is why it is important for you to contact your insurance company.  Ask them what wt. loss surgeries it covers.  Does it cover the VSG or sleeve (if that is what you are interested in)  I have read that some ins companies do not cover it because they feel it is "experimental".  And yes, get everything in writing!  If you don't get the answers you want, call back and talk to someone else.  Ask them if they have someone who is experienced in answering wt los surgery questions you can talk with.

RE: my experience with BMI, as I have read on the boards, the way some patients are treated by their Dr.s and offices, I am extremely happy with Dr. Joyce and BMI.  I never at any time felt that they were doing a "sales pitch".  I always felt they were very professional and caring.  One thing that really impresses me about Dr. Joyce is he is one of the Dr's that goes around and trains other doctors how to perform the Realize lapband surgery.  Both he and Dr. Lehman have excellent reputations.  Their practice is a "Center of Excellence" which is a very good thing!

As far as telling you that you were 'approved", I am going out on a limb and going to say that even though that is what may have been said, I sincerely doubt that is the case,because in all instances BCBSIL PPO does require a variety of tests/supervision/wt loss before they approve.  So I would chalk the "approved" language up to a errant comment by a staff member.  Now, should that comment have been made, obviously 'NO" but while I understand your being put off by the conversation you had, I have never had that experience with them.  I would prbly tell Dr. Joyce of my concerns when you rec'd the all so he can make sure it doesn't/isn't happening to other patients.

Best of luck to you.  Please keep us posted.  we are interested and care about what happens.  Feel free to PM me if you have any questions I may be able to answer for you.  I hope all goes well!  Welcome to the IL board.  I hope we have helped you with our answers.

Georgie

Thanks to everyone for posting,

It's amazing how different my words look now after the people here were so supportive and kind. I kinda of appear like a...! Anyways, thank you all for your support, and certainly your experiences and advice. I did as you all suggested and contacted my provider. According to BCBS IL we have a 3k deductible and we have $349.53 left to meet, After that $349.53 we are 100$ covered. As to the type ofsurgery covered the lady at BCBS said that it is determined by my the criteria I meet. SO if my surgery is done by Jan 1, I will only have to pay this amount. If the surgery is NOT performed by Jan 1, then I will have to pay 3K. So I appreciate the advice here to call them. I would have most likely presumed the worst and half assed the rest of the steps needed for surgery just KNOWING I would eventually be turned down or discover it too financially prohitbitive. So Thanks to all again. Can anyone tell me how these deductibles are collected? We can swing the three hundred dollars in one payment but since I will most likely not be scheduled until after Jan 1 I will have to pay my 3K and that would have to be done a little at a time. Also, the BCBS lady said that doctors appointments aresubtracted from the deductible. For instance if the cost of my appt is $250.00 then my remaining deductible is $2750.00 and so on. The thing is we don't pay for doctor visits. So if Im correct in my thinking, all we have to do is go to the doctor 3K worth and I have no out of pocket for surgery? Is this right???

Thanks again!!!