X Post- Cancelled - *pre-ops READ THIS*

 

"A little learning is a dangerous thing;
drink deep, or taste not the Pierian spring:
there shallow draughts intoxicate the brain,
and drinking largely sobers us again."

Alexander Pope, An essay on Criticism
English poet & satirist (1688 - 1744)

Because the doctor I was approved for and scheduled for did not request proper authorization, I had to cancel my thighplasty with my alternate doctor.  The first doctor cancelled *me*, because I insisted on asking questions, and I'm glad they did, because they lied and said they approved Medicare (primary) insurance when they did not.  I called and checked my AARP Medicare plan, alerted the doctor's office, they called and cancelled me the next day.

The second surgeon sang  the same tune as the first.  They do not pre-authorize Medicare prior to surgery, but bill afterwards. I had already received  prior authorization from Medicaid.
No prior authorization,  as most of us know, *guarantees denial from any insurance, public or private* and is a tactic used to strongarm patients out of cash who have it to pay, and weed out those of us who are less than middle-class or affluent.  I was middle class before lupus and fibro took over. Not anymore. My weight loss surgery helped bring  getting off disability within my grasp.  Medicare  is not welfare, but senior/disability health insurance that my tax dollars paid for when I was working.

I'm convinced that this tactic is used as a form of economic discrimination.  I did go to college, and had a very rewarding and well-paying career, until SLE and fibro took over,  so I don't fit what most doctors assume when profiling low-income patients:  that they are uneducated and maladapted to life in general.  It also doesn't help that I'm African-American.

That's right. Law enforcement is not the only profession  engaging in this horrendous activity.

First, I am on these government plans because of disability from lupus and fibromyalgia, not because I don't want to work.  I'm trying to get back to being productive. That was the whole point of the DS to begin with.  The steroid treatment for lupus helped push my weight up to 405 at its highest.  I am now at 165, just five pounds away from my PCP-imposed limit of 160 pounds pre-plastics, thanks to my DS, which was approved by and paid for with the same Medicare coverage I have now.  Just 20 pounds from my "chart weight" of 140.

My doctor estimated that 15 pounds of my remaining weight was skin and the uneven fat deposits clinging to it.

My surgery was reconstructive, not cosmetic.  I had been referred for thigh reduction after several bouts of cellulitis, which is an infection of the fat cells just under the skin.  The dermatologist that I was referred to determined that it was  being caused by abrasion from the compression garment I must wear to keep my lower body skin in place, enabling me to fit into clothes and walk.  Partly because my skin had been stretched out for so long, and partly due to genetics, it did not "snap back" after my massive weight loss.

Instead of empathy when I called to cancel, I got a chipper "OK, bye!" -CLICK-

I played by the rules.  I put forth the extra effort to personally retrieve and deliver medical records and make sure everything was in order. ****ep a set of every lab and procedure related to my weight loss surgery, and I even have a copy of my surgical report from my DS)  My Medicaid prior authorization expires June 23rd, and there simply wasn't enough time for me to do another consult and find someone who would do the prior authorization correctly.  I have Medicaid because of disability.

This was a year and a half in the making.  I went to four consults after I'd lost the majority of my weight. Only one surgeon said he would not do the surgery. 

Perhaps if I had not exercised due diligence, and just played dumb, I would be having my surgery, recuperated  during the summer and be on my way back to school in the fall.

I was seeing light at the end of the tunnel.  Now all I can see is darkness once again.

Lesson:  DUMMY UP WHEN NECESSARY!

 I'm really sorry you are having such crappy luck. But "medicare" never pre-approves anything ahead of time. If the surgery is a covered surgery under their guidelines, then medicare will pay their normal 80% of what is usual and customary. 

Ihave AARP Medicare Complete, and they said I need prior authorization for *all* surgery.  It's administered by United Health Care

Then you don't have "medicare". You have a plan that is funded by Medicare, but has completely different rules. Your Medicare Supplement plan/HMO is different. You have MC through United Health Care NOT Medicare. You actually temporarily "opt out" of National Medicare when you select a Medicare HMO, which I believe your plan is.

Medicare (meaning National Medicare administered by the government) will not pre-certify for anything. So try not to jump to the conclusion that this is somehow a commentary on your intelligence, your disability, economic status or your race. Fact is, the office my not understand your plan and it's YOUR job to understand it in full.

Next time, research the requirements of your plan so that you can comfortably repeat them to the office. Explain to them which plan you ACTUALLY have, and see if they take that one. They may not, and that may be where you're running into issues. You do NOT have "Medicare" which is a traditional fee for service plan. You have a "managed medicare plan".

First, there is no such thing as an HMO in Indiana, at least, not the part where I live.

There are PPO's, which is what AARP Medicare Complete is.  The largest city, and state capital, Indianapolis might have HMO's, but when HMO's came into vogue in the 1980's I was living and working   -yes, WORKING- in Illinois, and Indiana did not have HMO's then.  I was a member of an HMO where I lived and got excellent care!

I did research and I did everything you said to do this time.  I don't know what else I could have done to change the situation.   I showed them my card, which says what it is in big red letters on the front!  It clearly says AARP.  Perhaps the folks in the doctor's offices have a reading problem? 

They simply refused to dial the FREE provider service number and do what was necessary, because they knew they were not going to get the full cash price for the surgery that I need.

I'm not the first that has experienced this,  I have heard from others who had the same thing done to them, not for this type of surgery, but for other types, then got left with a big bill because the surgery did not get prior authorization.  It may be a problem  exclusively with AARP.

I'm not the type to go timidly shuffling away when there's an issue regarding my health care, especially something that looks and smells so much like economic discrimination.

Just the way Medicare Advantage plans work...they follow the payment rules of Medicare...even tho they technically require pre-authorization, if Medicare doesn't pay for the service, the likelihood of a Medicare Advantage plan paying is zip, zilch, nada!

And Medicare ALWAYS decides after the procedure if they are gonna pay not before. Read thru what you were sent by AARP. I suspect that a panniectomy is not covered unless covered by original Medicare. Most surgery to remove extra skin is considered plastics and therefore, cosmetic by Medicare regardless of how it's coded.

It has absolutely nothing to do with race, religion, socio-economic status, etc...it's just the way Medicare and the suppliment plans work.

We all play by the rules but Medicare has it's rules and nothing the doctors can do...in fact to find a doctor willing to accept Medicare is almost impossible and getting worse.

Liz

Thanks for your reply...but I don't need a panniculectomy. Even at my heaviest, I always had a flat tummy in proportion to the rest of me. My butt and thighs is where I carried the weight. If it weren't for the infections from my compression garment, I'd be perfectly happy wearing it or a girdle or some other kind of control garment. The extra skin is causing real health issues for me, and any doctor will tell you it is not good to constantly be on one antibiotic or another.

Rather than go through any more distress regarding this issue, I have decided today that I will no longer pursue this.

Honestly, I would rather have died from SMO related illnesses than being stuck with what I have now.
I can never wear a bathing suit in public again, and water exercise was my lifeline to health!

I'd rather have the fat back than be permanently disfigured!!

I understand but the panni is the ONLY part that Medicare will pay to remove cause everything else is considered cosmetic. It isn't for you but they consider it that...

Liz

My Medicare Complete plan is administered by United Health Care. It is not a supplemental plan..it is my Medicare primary plan.  medicAID is my secondary insurance.  They gave prior authorization for the surgery.  United Health Care  follows the rules for their private health care plan, and since my Thighplasty is medically necessary, they will pay for that if it's medically necessary.  I checked.   The issue here is that both surgeons insurance and billing departments refused to even call the provider line for United Health Care to obtain prior authhorization.

This issue has cased too much stress for me, I'm chewing up Xanax like SweetTarts, where I was only taking them on an as-needed basis.  I now take three a day, whch was the original prescription directions, to treat insomnia and anxiety disorder.

As of Sunday, I just made the decision to not pursue this any further, other than calling Legal Aid, to stop this tactic plastic surgeons are using to weed out low-income and older patients. I also intend to call my state's insurance commission and report this, not so much for me, but to make sure doctors who do this are exposed and sanctioned.

Thing is, it's any insurance company...not just Medicare or Medicare advantage...

As for weeding out those on Medicare/Medicare Advantage plans...since they pay so little, better get use to it. It's simply gonna get worse as more and more doctors stop accepting Medicare/Medicare Advantage plans. Since they only get paid. Example, my surgeon who did my DS charged 15K, he was PAID 1845.90...BIG difference. I'm really surprised he is STILL accepting Medicare/Medicare Advantage plans at that rate. (and yes, mine is also a medicare advantage plan.

So do what we did for my husband...get your plan out (or download them again if you have misplaced them cause ALL insurance companies send a copy of your benefits to you) nad have it in writing that it is covered. Do not depend on anyone other than yourself to get that correct inforation to the insurance person at a surgeon's office. They can't know everything and your plan may have differences than the standard plan. We had to get OUR copy of the explanation of Benefits to my husband's surgeon to get his DS covered...otherwise he would have had to do a 6 month diet. With the documentation in front of the insurance person, she got the CORRECT info and he was approved without it.

Liz