Insurance Question Regarding Nutritional Part of Surgical Program

I am asking if anyone out there has had the same issue I am having with insurance coverage of the nutritional portion of the surgical weight loss program. I am finding concerning inconsistencies in this. I have Harvard Pilgrim and in the Schedule of Benefits it lists under Covered Services and I quote "Medical education including nutrtional counseling." The program at Mass General has $925 of "uncovered services". Though I have gotten mixed and varying answers on what exactly this is for, I am told mostly that it is from the nutritional portion of the program. I am unable to pay that and so my scheduled surgery on July 22nd. will have to be canceled. I am very concerned about insurances paying for this expensive surgery and yet not covering the most vital part of it. I have worked hard to prepare for this surgery and I am very upset that I will not be able to have it because I cannot afford the uncovered services. Not paying for the nutritional counseling for bariatric surgery is akin to paying for an amputation but not therapy to teach a patient to walk again. I am outraged and disheartened by this and I plan on pursuing this MUCH further with my insurance company, right on to insurance commission in MA if I have to.

A lot of surgeons/hospitals charge a "program fee" which is never covered by insurance. It is an out-of-pocket expense. I know at B&W where I am going it is $500. The insurance does cover the nutritional counseling, but the fee is not part of that. It is a fee they charge for things they are not reimbursed by insurnace for, like phone calls, the support group meetings they host, the surgical information meetings, etc. I have heard that most surgeons, all over the country, are starting to charge such a fee. I even heard from a woman in Kentucky or Tennessee or somewhere down south that the fee was $4400. This fee is never even submitted to your insurance company. It is not easy, I know. I am a single mom of 2 and by no means rich, but I figure the sacrifice now would be worth it in the end. Good luck to you! Carrie

I have Harvard Pilgrim and they covered my nutritional stuff at UMass with no problem at all. So it's not that HPHC doesn't cover nutritional stuff. It may be that the program Mass General has set up is not an HPHC provider, or it may be that the kind of nutritional stuff they're doing isn't covered by HPHC. Or, as has been suggested, the fee may be for something else entirely. I started the program at New England Medical Center, and they said my behavioral/psych stuff would be out of pocket for me as they are not HPHC providers. My psych stuff WAS covered at UMass, although UMass now has a $350 or so fee for exercise and such at their program, which they didn't have when I went through it last year. I believe NEMC had a $400 fee when I started there, which did not include the psych stuff or anything else. Mary Ellen

I just signed up with Beth Israel in boston and they also have a $500.00 up front charge to get into the program (Tufts New England Medical is more up front about this, it is listed on their web page) I was a little angry about this at first.. the hospitals agree to accept the "usual and customary charges" when they sign up with an insurance company and shouldn't be charging an additional "fee". But in the long run it will be well worth it.

Sally, At the Brigham they do disclose the fee-but also say if that is a financial barrier to the surgery to discuss it with your surgeon. The surgeon has the ability to reduce or wipe out the fee. I went to addl info sessions with friends and this was re-iterated both times (for a total of 3 times including my info session). Ask your surgeon if they can negotiate or wipe out the fee! Joan

I have Tufts & had my surgery at Saints Memorial Medical Center - the only out of pocket expense to me was the usual $15.00 co-pay for each Dr. Visit and a $100.00 co-pay for the hospital. I needed to get refferals from My Dr. for the nutritionist but it was covered. I've heard of some hospitals charging a non-coverd fee (around the ballpark of $500.00) But Saints did not. Maybe you can contact another hospital and see if they will take you on as a patient & allow all the testing you've had at MGH into their program? Good luck, ~Jenna

Hi Sally I agree with Joan that you should definately discuss this with your surgeon. I work with two programs in Boston, one has a program fee, one does not. I have run into issues with insurance coverage when I bill for a nutrition visit. Some insurances cover the surgery but not the nutrition visits! I called one insurer and they said it wasnt covered unless the patient had anorexia, bulemia or diabetes. It was so frustrating and akin to the amputation/therapy analogy. One program I work with does charge a program fee and I do not have to bill for services. This is wonderful because I can see patients for whatever they need (15 mins or 45!) and not have to worry about them getting a bill for services or getting referrals. Its frustrating on your end, I understand that, but a program fee that partially covers nutrition is well worth it in the end. The other things the program fee covers include the support groups, info sessions, phone and email support (which I would at least spend 45 mins per day on), etc. Insurance companies are picking and choosing as well as changing the rules, and I cannot stress enough that a patient needs to be their own advocate and know what is covered and what is not..It is so frustrating! Mgh has a great program, as do all the programs mentioned. Take care Natalie