I don't jump through hoops well! Some comments please.

Oh, where to start - I haven't gotten my first consult scheduled yet and am getting frustrated.

It will be four weeks Monday that I e-mailed my request for consult and referral form from my PCM to Bayview Bariatric. My insurance is US Family Health Plan (TriCare at Johns Hopkins).

During this wait for Bayview to call and schedule, I phoned USFHP to find out what their requirements are for approval; supervised diet, tests, etc. They told me that the doctor's office would tell me all of that.

Tuesday (the 15th) evening I went to Bayview for their informational seminar. It's basically what's on their website, but you get to meet some folks. I mentioned what USFHP said about them supplying me with the requirements. JH says "No, you have to get those from your insurance company. We have our own requirements, which may or may not be what your insurance demands."

So yesterday, I call USFHP back and ask for the requirements again and am told that they won't give them to me, my doctor has to contact their Case Manager.

Last Friday (the 11th) I called Bayview to see about scheduling the consult since it's over 3 weeks and no one has called. I followed the phone promts to a message that said "I'm out of the office until Wed the 9th, don't leave any messages on this number" What? Ok, so I call back and follow different prompts until I get Alice who says she'll check into this and call me back, or someone will call me the first of the week.

It's a week later and still no call! So, how do I find out if I have to do a supervised diet? They already lost me a months time in starting it. And at the seminar they said that some insurance companies are really picky in who supervises it. What's a person to do?

And, one other thing - USFHP did they me that by my policy, with proper physican documentation, they cover 100% for gastric bypass and lapband. Would this include the sleeve that doesn't bypass anything?

Sorry for rambling and venting; and thanks for your responses.

Penny

Yes, there are a lot of hoops to jump through.  Yes, you will get the run around from some people.  But if you are determined to have the surgery you will jump as high as they tell you to.  I would call the doctors office and get the procedure code.  This is how the insurance company is billed.  Then call the insurance and see if your policy covers the procedure code.  The pre-surgery qualifications were something that was difficult for me to obtain as well, but after many phone calls and e-mails to their web site, someone finally told me that I did have to have a 6 month supervised diet.  Luckily my insurance didn't specify through who, so I went to my pcp.  Keep calling until you get your answers from the insurance company and the doctors office.  If you don't feel your getting service from your doctor, maybe you will decide to look at others.  There are many good surgeons in our area.  We are fortunate. 

Hey Penny,
Plain and simple, you need to become a pain in their asses.  No way to sugarcoat it.  You need to call the insurance company almost daily, as well as the doctor's office.  I would never wait a week waiting for them to get back to me.  At the very least, I'd call both every other day until you find out your requirements and get a date to come in and go over everything with the surgeon.  It's your right.  I've never heard of an insurance company that said it was up to the surgeon to decide on your requirements to be approved for surgery.  Hell, if you have to, drive down to the doctor's office and just walk in.  This way, they have to deal with you.  Remember, it's us patients that allows them to drive around in their Lexus, Mercedes and BMW's.

Hey Penny!

Remember one thing in all this YOU are the CUSTOMER. They are the service provider. DEMAND what you need to know. Also does your insurance company have a website? I have Aetna and did some digging on their website to find out what the requirements were for the surgery.

I have gotten a similar run-around...my insurance company said they can only tell a doctor what the requirements are for coverage (supervised diet, history of BMI, psych eval, whatever they may be), they can't tell me. So, I called my doctor, and they said the surgeon's office would do that. Well, if I don't know what's covered when, why would I make an appointment with a surgeon? I'm still researching surgeons, but I want to know if I need the 6 months diet or not so I can start it NOW!

I'm currently waiting for a call back from my doctor's office AGAIN (I called this morning--I don't wait a week!). If they don't tell me what I need to know, I will be calling my insurance company and demanding information--I will talk to supervisors, managers whoever--it is MY policy, and I deserve to know what my specific benefits and requirements are!

When I had problems getting information from my insurance co, I contacted the human resources people where I work and they were very helpful in getting the info for me.  Just a thought.  The insurance companies really try to make it tough for you so you'll give up - don't let them win!!! 

Thanks all for your replies. I did 10 years in the Navy and can really talk like a Sailor when I  get  my dander up. Hoping to not do that on the phone with the  insurance co. or the surgeons office. I've cooled down some today, but I'm sure to heat up come Monday morning.                                                                                                                                   Stopped by my favorite store after work (Barnes & Noble) and found a kewl Hogwarts journal to start documenting this journey in. Also a 3 ring binder to keep all the doctors receipts, reports, etc. 

                                                                                                           Jill, we're in the same boat, I'm waiting to get a consult with Dr. Schweitzer. One suggestion was to search for another surgeon, but it would be silly to pass on the only five star Bariatric Surgery Center in the state. I learned Wed night that a self pay Sleeve at JH is $17,500.

 

Well, thanks again everyone; see ya round the boards.

 

Penny

 

 

 

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I was told their rules changed this month--can't have a consultation with a surgeon (Schweitzer****il you've gone to their free information session. Have you gone to one of those yet? I'm going on Aug. 5 in Columbia.Maybe it is different for you since you have a direct referral--my insurance does not require a referral.

Jill,

Wed night they mentioned that they changed that rule on 1 July. I'm not sure why, but I went to the info session Wed night just in case there was some rule that they wouldn't schedule me without it. SPOOKY! Now I'm wondering how long it will be from the time they call to schedule until the appointment. Your appointment was already scheduled, so I wouldn't think they would hold you to that requirement, or they would call you. Good Luck!

Penny

As one of your fellow hoop jumpers and impatiently waiting preops, I say welcome to our world.  It sucks but we all have to keep at it and never give up. Do not give up and we are here if you need to vent.  I would be surprised if the surgeon wanted you to do a supervised diet when your insurance does not require it.  That costs tiem and money out of your pocket too.  I would give your insurance the procedure code for the sleeve and then see if they cover it.
 
Here is what Dr. Schweitzer has posted on his website www.smallscar.com regarding CPT procedure codes for WLS.  

"You will need to know the CPT codes the surgeon will bill 
(see below) 
43644 – Laparoscopic RNY Gastric Bypass 
43770 -  Laparoscopic Lap Band code 
There is no specific laparoscopic Duodenal Switch with BPD cpt code currently in place so when calling your insurance company tell them 43659 & 43845 (open duodenal switch with bpd code). 
There is no specific laparoscopic sleeve gastrectomy cpt code currently in place so when calling your insurance company tell them 43659 & 43843 
43659 – unlisted laparoscopic stomach code (we submit a letter with the open and laparoscopic code but will bill in most cases using the unlisted laparoscopic code) 
43846 – Open RNY Gastric Bypass 
43848 – Revision from a vertical banded gastroplasty to  RNY Gastric Bypass "

I hope you get there soon!
Jennifer