interesting insurance news
So i found out just before PATS that my insurance (AETNA) woudl only cover at out-of-network rates, so I had to cough up a huge chunk of change personally. Wasn't easy! And I was upset about it because when I had started investigating this option more than a year and a half ago, I had started by calling the insurance co. I was told that there were NO in-network bariatric surgeons in this region and that, as a result, the surgery would be covered at in-network rates even though Barix was out of network. When barix did the pre-cert, however, it came back the other way.
Being 2 weeks pre-surg and incredibly stressed out at work and home and in prep, I told myself that i would NOT let this derail me and that I would investigate post-surg when i had time to think.
So I've gotten two calls from a wonderfully supportive followup nurse at Aetna. Today, I mentioned the financial stress to her and how upset I was about it, and even though I KNOW it was not her job to do this, she looked into it for me. Turns out that (note this for all you who have not gotten pre-cert via Aetna yet):
BARIX MUST SUBMIT THE PRE-CERT AS A "NON-PAR" PROVIDER DUE TO DEFICIENT NETWORK, not as an regular out of network provider. By doing this, Barix gets paid at the higher in-network rate, because the network is considered "deficient." Aetna doesn't check to see whether there's an in-net provider in your area automatically, they just assume tha tyou went out of network out of choice.
Now, apparently, I can appeal the cert (and will definitely be doing so), which means that I may get some of that money back (and wouldn't THAT be awesome). But it would have been so preventable in the first place, apparently, if I had known (and if Barix had known) what to say.
I know there are many flavors of insurance out there, but if any of you are dealing with the whole in-/out-of-network hoo ha, this might help!
Karen
Being 2 weeks pre-surg and incredibly stressed out at work and home and in prep, I told myself that i would NOT let this derail me and that I would investigate post-surg when i had time to think.
So I've gotten two calls from a wonderfully supportive followup nurse at Aetna. Today, I mentioned the financial stress to her and how upset I was about it, and even though I KNOW it was not her job to do this, she looked into it for me. Turns out that (note this for all you who have not gotten pre-cert via Aetna yet):
BARIX MUST SUBMIT THE PRE-CERT AS A "NON-PAR" PROVIDER DUE TO DEFICIENT NETWORK, not as an regular out of network provider. By doing this, Barix gets paid at the higher in-network rate, because the network is considered "deficient." Aetna doesn't check to see whether there's an in-net provider in your area automatically, they just assume tha tyou went out of network out of choice.
Now, apparently, I can appeal the cert (and will definitely be doing so), which means that I may get some of that money back (and wouldn't THAT be awesome). But it would have been so preventable in the first place, apparently, if I had known (and if Barix had known) what to say.
I know there are many flavors of insurance out there, but if any of you are dealing with the whole in-/out-of-network hoo ha, this might help!
Karen
I'm so sorry to hear about your situation. I fully recognize just how frustrating and debilitating that can be and i wish i could help in some way.
I have struggled my entire life with my weight. I can't remember ever being comfortable in my own skin, even at times when i now look back at pictures and realize that I was a reasonable and healthy weight. What got me to the surgery point was an assessment of how many diet, exercise, and lifestyle changes I've made over the years, none of which address more than a small portion of the weight (which would then pop right back on as frustration set in). In prep for the insurance approval, i spent 6 months working with my doctor and a dietician and making dramatic changes in my diet... that got me all of 12 lbs of results (woo hoo). So i know what it is to feel stuck.
Not to play Dear Abby here, but what concerns me is your husband's reaction, and your caving in to it. His behavior really makes me wonder what he FEARS about you losing weight... that you'll no longer love him? Or that he won't remain "worthy" of you? He obviously has something driving him on the topic, and perhaps some joint counseling might help you both understand and deal with what's going on. And from your side, dear... if he won't eat unless you eat, so what? He'll eat if he's truly hungry. Seems to me it's time to put your foot down to defend yourself!
So you don't say where you are in PA, but I'd bet there's some type of support system... at a local hospital, church/synagogue, someone's house... it's only going to reinforce what you're going through and the feelings of hopelessness if you remain isolated. I'd bet if you post a "looking for support" here with a general area that you'd find someone willing to meet you or a support group. So far this group of people has been amazing in their willingness to go out of their way to help.
Anyway, I care and hate to hear you hurt like that.
Take care of YOURSELF.
karen
I have struggled my entire life with my weight. I can't remember ever being comfortable in my own skin, even at times when i now look back at pictures and realize that I was a reasonable and healthy weight. What got me to the surgery point was an assessment of how many diet, exercise, and lifestyle changes I've made over the years, none of which address more than a small portion of the weight (which would then pop right back on as frustration set in). In prep for the insurance approval, i spent 6 months working with my doctor and a dietician and making dramatic changes in my diet... that got me all of 12 lbs of results (woo hoo). So i know what it is to feel stuck.
Not to play Dear Abby here, but what concerns me is your husband's reaction, and your caving in to it. His behavior really makes me wonder what he FEARS about you losing weight... that you'll no longer love him? Or that he won't remain "worthy" of you? He obviously has something driving him on the topic, and perhaps some joint counseling might help you both understand and deal with what's going on. And from your side, dear... if he won't eat unless you eat, so what? He'll eat if he's truly hungry. Seems to me it's time to put your foot down to defend yourself!
So you don't say where you are in PA, but I'd bet there's some type of support system... at a local hospital, church/synagogue, someone's house... it's only going to reinforce what you're going through and the feelings of hopelessness if you remain isolated. I'd bet if you post a "looking for support" here with a general area that you'd find someone willing to meet you or a support group. So far this group of people has been amazing in their willingness to go out of their way to help.
Anyway, I care and hate to hear you hurt like that.
Take care of YOURSELF.
karen
Jackie - What part of PA are you in???
WE are your support system!! I am sorry to hear that you are having such a horrible time with everything. I think your hubby needs a swift kick in his favorite body part! Don't let him control you like that!!! If you need to talk I am here! If you are in the eastern part of the state we'd LOVE to have you to our support group / cooking class at my house!
Liz
WE are your support system!! I am sorry to hear that you are having such a horrible time with everything. I think your hubby needs a swift kick in his favorite body part! Don't let him control you like that!!! If you need to talk I am here! If you are in the eastern part of the state we'd LOVE to have you to our support group / cooking class at my house!
Liz
My Uncle used to live there! Unfortunately that is quite a drive from my house - I am guessing a good 4 hours.
1200 calories is good - but depending on how much you are exercising you could actually need to get to 1500 or your body thinks that it is starving and won't shed the pounds! Crazy I know!
Your menu sounds good to me. I can eat those things (except for the snack pack thing because of the sugar)
I too have an injured back - 6 decompressed or herniated disks in my lower back - I have chronic degenerative disk disease - herediatary unfortunately. I have been there the days I couldn't get into the tub to shower or raise my arms to wash my hair. Unfortunately this isn't always something that gets better with weight loss - I was down 100 pounds and it was the worst it had ever been!! Now I see a chiropractor regularly and it is working wonders!
I am sorry that hubby is such a schmuk! The good thing about sex is that it is exercise! lol
I hope that things turn around for you - my e-mail is [email protected] and my cell number is 610-462-1204 please feel free to call or e-mail any time!!! I also post the recipes from the cooking class on here the week after the class.
*hugs* hang in there!
Liz
1200 calories is good - but depending on how much you are exercising you could actually need to get to 1500 or your body thinks that it is starving and won't shed the pounds! Crazy I know!
Your menu sounds good to me. I can eat those things (except for the snack pack thing because of the sugar)
I too have an injured back - 6 decompressed or herniated disks in my lower back - I have chronic degenerative disk disease - herediatary unfortunately. I have been there the days I couldn't get into the tub to shower or raise my arms to wash my hair. Unfortunately this isn't always something that gets better with weight loss - I was down 100 pounds and it was the worst it had ever been!! Now I see a chiropractor regularly and it is working wonders!
I am sorry that hubby is such a schmuk! The good thing about sex is that it is exercise! lol
I hope that things turn around for you - my e-mail is [email protected] and my cell number is 610-462-1204 please feel free to call or e-mail any time!!! I also post the recipes from the cooking class on here the week after the class.
*hugs* hang in there!
Liz
Hi Karen, glad to hear that you got in touch with someone at Aetna who knows what she is doing. I work there and used to be in customer service. I did NOT know about submitting the claim like that, though. That could be something new that they do.
Please please please, send in a letter or find out the nurse's supervisor's name and give her a commendation of some sort. It is rare that we receive kudo's from customers and it means so much to all of us to receive them!! (just a thought)
Please please please, send in a letter or find out the nurse's supervisor's name and give her a commendation of some sort. It is rare that we receive kudo's from customers and it means so much to all of us to receive them!! (just a thought)
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