Warning - Dr. Moran was not upfront

My name is Karen.  My BMI is 37.5.  I went to Dr. Moran's free seminar to pursue lapband surgery.  I then proceeded to set up an initial consultation fee.  Dr. Moran failed to tell me that lapband surgery would not be covered if your BMI went below 35 in the past 5 years (Blue Cross Blue Shield - State Teacher's Plan).  I went  thru numerous, expensive tests for nothing.  I spent approximately $800 out of pocket just to find out that I didn't even meet the criteria to begin with.  In my opinion, this was Dr. Moran's responsibility to inform me about how insurance works since his practice deals with insurance all the time.  Just want to make you all aware before you spend lots of money and time.  I met all the other criteria - BMI over 35 with other medical conditions.  I guess the surgery was not meant to be so I will now have to go it alone - again!!

Karen,               I'm sorry you have had to go through this. I don't know your whole situation all I can do is tell you of my experience. Dr Moran is my doctor..and I have never felt that they have dishonest about anything. If he had a consult with you, I'm sure he only proceeded b/c he felt he could help you. There are so many  insurance plans out there..and even more FINE Print in those plans, it may have been a mistake on BCBS part......I don't know?? Before my surgery, I called insurance several times just to make sure I had all the correct information....even then there was some incorrect info given to me and Dr Moran's office. I hope you can find a resolution and continue on your journey =0)    ~Sarah~ 

Hi Sarah,      Thanks for your reply.   Did you have lapband or gastric bypass?  Are you happy with the results?  I am thinking about appealing the decision.  I do think that Dr. Moran's office should be aware of all the different insurance plans since they deal with them all the time.  I did find everyone in the office to be friendly however I do feel as if I have been taken advantage of financially when it didn't need to be that way.  I did call BCBS ahead of time and was told they only cover weight loss surgery if recommended by a doctor and if I meet certain criteria.  I asked for the criteria when I got to Dr. Moran's office.  I thought I qualified since my BMI was 37.5 and I have high blood pressure and high cholesterol and show signs of being pre-diabetic.  I have been overweight for the past 10 years ever since having 3 sons.  My last child was born at age 40.  I am now 44.  I do think I could appeal the decision but don't know what good it will do.  My BMI was below 35 in the past 5 years which makes me ineligible.  If I had known this upfront I would not have gone thru with all the testing and paid all the money out of pocket.  Good luck to you and thanks again for your response!  Karen

Have you called the insurance yourself to verify?? If DrMorans office should still send in the request... if BCBS turns you down you have the option of going thru the appeals process. For RNY bcbsNC (ppo) required me to meet a BMI of 35+ w/comorbs or 40+ w/o for 4 of the past 5 years... I did not meet this criteria... my surgeon submitted and I had to appeal 3 times but was finally approved for the surgery.

Hi Karen, I just thought I would add that my dad is going through the same thing you are... He went to a seminar about 2 weeks ago and paid $200.00 to hear a lady talk about lap band surgery and gastric bypass. He found out that he didn't qualify for the lap band because his BMI was too high. I forget what it was, but he decided that something had to be done (weighs 347lbs) and chose to go ahead with the gastric bypass. He had all the consultations set up and the first one he needed was the nutritionist consultation. So, when he arrived there, they wanted $200.00 more to basically tell him that he is overweight and needs to eat more healthy. He was not informed that he would have to pay this out-of-pocket expense when the nurse set up the appointments. They only told him that he would have to pay the 200.00 for seminar. He got really upset with this and decided just to go home. The next day, he got word that the insurance company BCBS of Georgia didn't cover bariatric surgery. I have tried to find out more on how he can still get this surgery performed. He doesn't financially have the money to pay for it. At Nash General Hospital in Rocky Mount, they told me that it would cost him approx. 25,000 to do the surgery. I contacted the insurance company and they told me that you can look into something called indigent care plans. Well, I had no luck there with the hospital either. They said it doesn't cover bariatric surgery, unless it's an emergency. My dad is 49 years old, has diabetes, high blood pressure, gout, knee & hip problems, back problems, and limited mobility. I think this is an emergency! However, they look at it as and elective surgery still. And, I found out that if he didn't work and have insurance, they would pay 100% for the surgery (MEDICAID). I just don't understand this whole theory. I am very frustrated for my dad, because he desperately wants to live a more happier, healthier, and active lifestyle. He just needs help! He can't exercise to lose weight because his knee and hip give out on him. What's a man to do? I feel so sorry for him and I truly understand where your frustration and heartache comes from. It's ridiculous that hard working citizens, even ones who are overweight and struggle to work daily on bad knees, backs, etc... to come home hearing the news that their insurance doesn't cover the surgery. I believe this is sort of a way for the hospital to make extra money or something and also a way to really hinder people from living a healthier lifestyle.Even the nurse said that if he was to quit working and apply for Medicaid that it would be covered 100%. This really isn't  an option for him!  Well, I truly hope the best for you and finding a solution to your problem and getting this lapband surgery approved! Wish me luck in finding a way for my dad to get the help he so desperately needs!

Hi!  I really appreciate your reply and your sympathy.  I feel really bad for your dad.  It is amazing how insurance works these days!  I was trying to do something proactive to help my weight situation but it didn't seem to work.  Yes, I probably will appeal the decision and see what happens.  I am about 98 lbs. over my ideal weight.  I am 44 years old and have 3 beautiful sons.  I have been going thru a divorce which only complicated matters with my eating and additional weight gain.  I do hope you can find some help for your dad.  I have also been told by others that the squeaky wheel usually comes out ahead.  Best of luck to you and your dad!  I used to live in Rocky Mount (for 9 years) and I am very familiar with Nash Rocky Mount Hospital.  All three of my sons were born there!  Take care, Karen

Karen,                 I have the Band and I'm right at 4 weeks post-op. So far I have been pleased. I will have a better idea of the whole situation after my first fill. When you said you had a BMI under 35 for the last 5 years...how long was it under 35..and how long ago? I would appeal to see where you stand after that. I'll keep my fingers crossed!! ~Sarah~

Karen, I had the same question, how far below BMI of 35 have you been?  I also have BCBS PPO, and they approved me.  My BMI at surgery was 43.9; but prior to that I would say that my BMI was down in the past 5 years around 37-38. I know Dr. Moran's office is really on top of things, and compared to others I have read about they know their stuff.  I do remember Dr. Moran saying in his seminar about the 5 year weight history; did you have him look at it before the testing was done?

Hi!  Thanks for your response.  My weight has ranged from 160 - 220 in the past 5 years.  I am 5 feet four inches.  I was 203 lbs. when giving birth to my son in 2003.  I then tried LA Weight Loss and lost around 30 lbs.  I did know about the five year weight history but did not know how important that would be in deciding whether or not I would be approved for surgery.  Dr. Moran acted like everything was fine for me because my current BMI was 37.5 and I have health issues on top of that.  I was given a sheet of insurance information when I had my initial consultation and there was nothing listed about being below 35 in the past five years.  Also, I believe Dr. Moran should have looked at my medical records before asking me to undergo all the pre-op tests necessary for surgery.  I just think that the insurance information should be submitted first prior to going thru all the testing.  I was not told that insurance approval was the last step.  I assumed (my mistake) that insurance was done first and then the necessary testing would take place after that.  I will try to appeal the BCBS decision but not sure what kind of luck I will have.  Did you have lapband?  Are you pleased with the results?  Karen

Hi Sarah,        My weight has fluctuated between 160 - 220 lbs.  I am 5 feet 4 inches tall.  In 2002, I was pregnant with my third son and gained about 60 lbs.  I believe I weighed 203 at the time I gave birth to him.  I then tried LA Weight Loss and lost about 30 or so pounds.  During the majority of the past five years my weight has been between 185 and now currently at 218.  It took me about a year to gain the weight back after losing 30 lbs.  I will look into the appeal process and see what happens.  Thanks!  Karen