Decided on DS, need assistance with Priority Health & the process
My insurance is Priority Health HMO. I have to have a 6 mo supervised diet with my BMI being 38. However, if the BMI is under 40 Priority health requires at least one co-morbid. I have none, but I know it is a matter of time.
My question is this... Do you think Priority Health will cover me WITHOUT the co-morbid? Or should I try to gain to get up to the 40 BMI which does not require a co-morbid? I hate to consider gaining. I have worked so hard to lose what I have lost over the last couple of years.
Also, say I lose a little bit of weight during my 6 months supervised diet and get below a BMI of 35 (minimum requirement for priority health) - does that mean they will not cover my surgery?
I have contacted priority health on these questions but they don't really answer them and give me the run around. I have requested their Bariatric Surgery policy but haven't received it yet.
Do I meet with a surgeon before I complete my 6 month diet? Dr. Kenmeeter from GHP comes up to our hospital and is affiliated (where I also work) so I would like to have him do the surgery. Thanks in advance for any insight you may have. I have an appt Wed. to meet with the doctor on starting the 6 month process.
I don’t know if this will help, but I will tell you what I know about Priority Health. I was with them up through last year. Back about 6 years ago I wanted to have wls. I did all the tests for co-morbidities and had a couple, but my BMI was not high enough to have surgery without the 6 months of supervised diet.
I did the diet. I had to go to meetings once a week for six months and pay $20 each time I went. I also had to purchase their High protein low calorie food. If I remember correctly; the cost of going and the food together for that 6 mo cost me about $2100.00.
I really gave my all too losing weight during that time and I lost about 80 lbs in 7 mo. I eventually put the weight back on, but was too embarrassed to return when the lbs were piling on again. When I was over the embarrassment and ready to seek help again it was too late. You must have wls within 2 yrs of your supervised diet for Priority Health to cover it.
I found out toward the end of this last year our company was switching Ins to BCBS and that under their plan I would qualify without the additional 6 mo diet. So I had the DS in March. I was charged about $27,000 for the DS and have had to pay about $1,500 of that with BCBS.
Priority Health has their guidelines online. You should be able to google them.
I hope this helps a little. And good luck on your wls journey.
I, too, have Priority Health. For several years I was looking into WLS, and unfortunately my BMI was not high enough and my only comorbidities were Hypertension and Hyperlipidemia. Nothing else. I had no sleep apnea, no diabetes, no heart or kidney issues...nothing. I was very, VERY frustrated to hear that they wanted me to go through their "medial weight loss" prior to even considering me for WLS. I went to the inital informational meeting and even went through the medical start up, before realizing how expensive it is.
For me, I had a young son and Husband and money was the big issue. It's expensive and we just didn't have the money.
Of course, skip ahead 5 years and a daughter later my weight was really high. I again, talked with my PCP who wasn't the most helpful but went directly to Priorty Health. I found out that my BMI was now high enough that they approved me for surgery WITHOUT having to do the medical weight loss portion.
For Dr. Kemmeter, GHP charges $1,000 from PH patients prior to surgery, this does not include the cost of your food or vitamins. I have had 3 additional bills from St. Mary's Hospital...two for anesthesia $200 and another for the surgery $300. So plan on shelling out about $1500 in just medical bills. We were lucky that with our flex spending account and tax return, this wasn't a huge hit to our household.
Dr. Kemmeter is AWESOME. He is the most caring, compassionate and kind physician I have ever met. GHP is fantastic from the exercise physiologist to the Dieticians. You will be in excellent hands.
Dr. K was great and I felt very comfortable with him. He has a very good track record not only with doing first time DS surgeries, but also with the very difficult revisions to DS surgeries. He has never lost a patient.
We are lucky to live so close to a talented surgeon. Many people travel from out of state to have him do their surgery. I would not hesitate recommending him and GHP to my closest friends.
Revision from RNY to DS 12/10/12 Dr. Ara Kesishian BMI: 19
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