Self Pay??

How many of you folks were self pay due to denial from your insurance?

I am. And we have the same surgeon, so I can give you some info if you need it. I was denied because my employer qualifies as a small business and therefore doesn't have to cover anything obesity-related.

Liz, Any information you can provide will be greatly appreciated.

I'll reply here, in case others are wondering too. For Dr. Kligman's office, the woman in charge of self-pays is Peggy Pardot (Pardoe?). She'll send you a legally binding contract, and you'll wire them $25,000. That is the up-front cost, and it covers the surgery and one- to two-night hospital stay, not the post-op appointments or any complications. (I'm not sure if it covers the pre-op tests -- I'll find out soon). The staff keeps that $25,000 in a fund for you and pays your bills as they come in. Peggy said many people are reimbursed $1,000-$3,000, but of course there's no guarantee that it won't cost a little more.

Hey Liz, I'm glad everything worked out for you but I hope that you got more clarification on your denial because my employer covers their employees under a "small business" health plan and I was approved on the first try. It's great that you were able to do this self pay, but I don't want others to read your post and think that they HAVE to be self pay because they are employed by a "small business". I'm sure it was more based on the type of insurance your employer provided, not just the fact that they were a small business. Have a great holiday!

Roni, The difference in your case was that your employer either already had, or was able to obtain, the required "rider" for their health insurance policy that covers WLS. The small group employer health insurance policies in Maryland are not required (mandated) to include WLS coverage, and the standard policy marketed in Maryland will exclude it by default. Moreover, there are a number of health insurance companies which simply will refuse to sell the rider, even where the employer wants to purchase and pay for it. Leesa

Thanks Leesa, Perhaps one or both of us are not reading the mandate correctly and it could be me, but my first thought is that a mandate is in itself a requirement. So the mandate for the WLS, at least the way I read it, does not exclude small business employers. It's a mandate to the insurance companies requiring them to provide the benfit, not provide the benefit to only large business employers. http://mlis.state.md.us/2001rs/90-day-report/Volume%20I/partj.htm I think you are referring to the Small Group Reform, which basically guarantees the comprehensive standard benefit package to small business employers at a rate not to exceed 12% of the average wage. It's a bill that makes insurance more affordable for small business employers to offer insurance to their employees. It has a small blurb about excluding pre-existing conditions, but it does not, in my opinion, outweight the original mandate for this coverage. I promise you that my employer, which is very small business and only 3 years old, carries the comprehensive standard insurance policy for all employees. I personally picked the plan in March 2004 and it did not already have the "rider" and we did not not buy into the WLS coverage. Simply put, the insurance company we picked followed the mandate and included it, the fact that they are a small business had nothing to do with it. I just don't want people who log on for the first time ever to read a post like this one and get discouraged because they too may be employed by a small business and automatically think they HAVE to be self pay because even if both of us are partially reading the mandate and the house bills wrong, it still does not work that way.

Roni, The mandate which you refer to is silent in its language as to the applicability to large group employers vs. small group employers. However, the Maryland Insurance Administration (MIA) will confirm that the statute only applies to require/mandate inclusion of WLS in the large group employer health insurance plans. The Maryland Health Care Commission (MHCC) is the state body that is tasked with determining annually what is to be included in the comprehensive standard benefit package the premium for which, as you correctly noted, is limited to a rate not to exceed 12% of the average wage. There is language in Title 31 of the Code of Maryland Regulations (COMAR) which excludes weight loss surgery and other treatment in conjunction with the comprehensive standard benefit package: 31.11.06.06 .06 Limitations and Exclusions. A. A carrier shall apply the limitations and exclusions specified in §B of this regulation to the covered services specified in Regulation .03 of this chapter. B. The following are exclusions and limitations to the covered services: ...... (14) Medical or surgical treatment for obesity, unless otherwise specified in the covered services; (15) Medical or surgical treatment or regimen for reducing or controlling weight, unless otherwise specified in the covered services; ..... In a telephone discussion I had a year or two back with the (then) main legislative person at the MHCC), I was told that it was unlikely that the MHCC would be likely to consider requiring WLS to be included in the comprehensive standard benefit package, in that WLS was, basically, in competition with other medical treatments fighting, as it were, for inclusion in the plan. If your employer's health insurance carrier chose to include coverage, consider yourself lucky, and that insurance policy as an exception, rather than the rule. As co-founder and co-chair of the grass-roots Maryland Weight Loss Surgery Legislative Action Committee, I have been relatively active in the past few years in connection with health insurance coverage for weight loss surgery in the State of Maryland, although achieving mandatory coverage for all health insurance plans covering Maryland residents has not yet been achieved. Leesa http://health.groups.yahoo.com/group/MD_WLS_Legislative_Action_Committee/

I truly understand what you are saying, and I agree that it happens too frequently, but I guess my concern is that you seem to interpret how MHCC uses the mandate as a matter of law when that's not the case. I'm reading and re-reading and I do not see anything that specifically states that the regulations apply to only large businesses. There are certain requirements to the mandate, as applied to each insurer, to each policy. They have that right. But the mandate is that they privide the coverage, period. I guess what I don't understand is how much more mandatory can you get then a mandate that requires insurance companies to provide the coverage? Which is what we have. Yes, I am lucky, I didn't have to fight tooth and nail to get approved, neither has thousands of others. I am not at all an advocate for insurance companies, they suck for the most part. But I still disagree with discouraging others from even thinking that they stand a chance. You specifically state that we have not yet achieved a mandate requireing the coverage and in fact, we absolutely have. For obvious reason, insurance companies are not required to pay for or approve every request for WLS, but the coverage is in fact there whether you work for the small businessman or the Donald Trump of Maryalnd. I understand where you are coming from, I just disgree with the way you are interpreting the regulations. Thanks for the insight though, its been a pleasure.

Roni, The same Title of the Code of Maryland Regulations -- which is Maryland law -- which I referenced above with regard to the exclusionary language identifies the applicable scope for the comprehensive standard health benefit plan as follows: 31.11.06.01 .01 Scope. A. This chapter applies to all carriers that offer the comprehensive standard health benefit plan to the small employer market. B. This chapter identifies the uniform benefits which must be offered in a comprehensive standard health benefit plan which a carrier offers to a Maryland small employer if the policy is issued or renewed after June 30, 1994. A carrier participating in the small employer market shall market this plan to: (1) All employees with as few as two eligible employees and as many as 50 eligible employees; and (2) Self-employed individuals. ******************************* The Maryland Health Care Commission has the authority under the above portion of the Code of Maryland Regulation to carve out an exception to the mandate. That carved-out exception has been upheld by the Maryland Insurance Commission.