Is Insurance CS Pulling My Leg?m

I'm just starting my weight loss journey...again. I had the lap band in '08 and lost 130lbs but it slipped and almost killed me in '12. Since then I've gained 150lbs. Anyways... I now have GEHA and just got off the phone with customer service. She said my requirements is the BMI (mine is over 40) and the six month supervised diet within last 12 months BUT the six months does not have to be consecutive. I told her I've had a gym membership at the hospital for the last several months and I've been to different doctor visits over the last year where I've had my weight documented. She told me that should all work for the 6 month requirement!! Do you think she doesn't know what she's talking about or it seems legit? Does anyone with personal experience with GEHA (or United Healthcare) know if they are pretty lenient in regards to the 6 month diet? 

I can't say for sure, but I have read on these forums that they are pretty strict. I would ask to be sent a copy of the policy where it says that , and read it for myself.

Dig out your handbook, or go online to read your policy. Every policy is different, so we cannot say.

Why bother - your surgeon, not you,  is the person who submits for ins approval.  It only matters what the ins co tells your surgeon.  Get an appointment with a surgeon and get that process started and see how it goes.  Why wait one more day??

Working with your ins co is like getting the cart before the horse.  Your surgeon's office has an ins specialist who probably already knows more about your policy than you do.

A referral from her PCP might be needed for the visit to be covered or surgery might not be covered unless she goes to an in-network doctor. It's not a waste of time to do homework, know the policy, and NOT blindly rely on someone else.

That sounds like a good answer, but in reality, what matters is what the ins co. tells the surgeon.  You do not even submit your package for approval, the surgeon does.  So, whether you like it or not, you will rely on the surgeon to get the ins approval.  They usually have great staff that are ins specialists - and are more help than an ins cust serv rep. 

Read your policy and do all the HW you want or feel you need to, but the important thing is to get the process started. 

Why so salty? I do know whereof I speak, since I've done this professionally for years. 

I'll be peppery this time. (with a smile)

I think there is often confusion on the part of people just beginning the WLS journey that they will have to work through all the ins issues on their own.  While I may have had a more gifted office than most, I knew my ins covered it, generally, because I knew someone who had WLS with my same ins.  Other than that, I followed the checklists I was given.  The surg submitted for app, a week later I was in the OR.

I'm not saying that you don't know what you are talking about, just that the surgeons are primarily resp for getting ins approval and have resources in their offices - perhaps someone like you.  Therefore, people who are interested in WLS do not need to work though all the insurance issues on their own.  IMHO, it's more important to get the process started and work through the ins issues as they crop up.

I read lots of posts from people who are trying to figure out all the insurance req and they haven't even scheduled a public info meeting. Let the ins pros help with ins approval.

I say just get started. 

Okay, I see. I often advocate starting with the PCP, but only because so many payors now require a referral, etc, and a lack thereof is grounds for denial of coverage.

There have been a run of posts lately about people getting to the cusp of surgery only to find it is not covered or something has been missed. It is sometimes shoddy work on the part of the office; however, that's why I advocate doing homework.

Ready for this - at a Support Grp Mtg 2 months ago, they told us that some ins co are going to require a 3 mo pre-surg EXERCISE program.  (actually this makes more sense to me than a 6 mo diet because you really do need to get moving after surgery and some of us were pretty out of shape before surgery).  So my doc has teamed up with a local PT group to develop an exercise program and at the Supp Grp Mtg they were telling us what was available in case some people were interested.  What more will they think of next?