I am a go to person with Insurance Problems

The older people on the boards know me, I am Vicki B they call me the insurance GURU.  I have 30 years experience with medical insurance and medical review etc.  I work with anyone that wants my help researching, answer insurance questions, or appeals.

I do this as a volunteer service to those who need it .  I am not a lawyer just a lay person that knows the ins and out of insurance and how they tick.   You can always email me or PM me.   My email is Vicki [email protected].

Need help I am there for anyone that wants it

Vicki

hi Vicki,

Are you enjoying your new job?  Happy to see you.

Wendy

i love it.   I am volunteering 2 days a week a couple hours a day.  I am in Florida right now was to be a vacation but has turned into family crisis but will be be back to work in 2 weeks I miss the people I work with..

How are you doing Wendy

I know I PM'd you the other day, but I am having a hard time getting a straight answer about something from BCBS (it's the blue access ppo)...I'm seeking approval for a revision and am obsessing over the criteria..lol.  I have read the "bariatric criteria" online many times on their site, and when I talked to a representative, she mailed me out the "exact criteria" (which is the same thing I've been reading.)

Basically it's something like this:
-A person must have a BMI of 40 OR a BMI 35+ with serious comorbidities
-They need proof of previous non-surgical weightloss attempts and supervised diets
-Be declared "sane" or whatever
-Be "educated" on the surgery (NUT visit, etc)

then it goes on to say something like this:
"For surgical revision of a previous bariatric surgery, there must be something mechanically wrong with the surgery - such as band erosion, staple line disruption, fistula, enlarged pouch due to vomiting, obstruction, etc"

I have previously had an obstruction, I have a "slightly enlarged pouch" and massively dilated stoma (I didn't ever eat too much but I never felt full and "heaved" a lot early on after surgery), and I had a staple/suture come loose (but most of the pouch is still "intact")...My BMI is right @ 40.  All I'm trying to figure out is if revision patients have to go through the "6 month diet", "5 yr history of morbid obesity", serious comorbidities, etc...OR if just the bottom half of the requirements is the only criteria I have to go by. (Mechanical failure)

No one understands my question when I ask them, lol.. maybe you know how to read into it. :)

Nene thats what we call my youngest grandaughter. Anyway.  Here is how I read the medical policy you say you had a dilated pouch and that you heaved a lot, that fits the enlarged pouch due to vomiting and obstruction.  your BMI is highover 40 or at 40 .    Now if your doctor has documented this then no problems with the other stuff.   It would follow the criteria for revisions alone with out the BMI and etc.   Give it a try have your doctor submit it for approval and see where it goes.   At that point you can appeal if it gets denied but I dont think it will if your doctor has documented the findings for a revision

I guess I will bring all of my endoscope findings and proof of significant weight loss @ first, then weight regain after the first 6 months or so...and hope that the surgeon writes a really good "medically necessary" letter.

I'm reallly hoping they just go by the "mechanical problem" criteria, lol.  I've been to the doctor tons of times over my weight and desperate enough to get phentermine... I was just never able to find a dr who would prescribe it  for 6 consecutive months...haha.

Thanks :) 

 You're awesome, Vicki. Thanks for helping everyone.  The insurance aspect is so overwhelming!

Vicki, I know I'm going to be using you quite a bit over the next few weeks.  I'm trying to get my ducks in a row regarding insurance before I go to my PCP or contact any surgeons...why waste their time if I know from an insurance standpoint, we won't be able to afford it, right?

Anyway, I just wanted to thank you for making yourself available to people like me who are completely and utterly confused or overwhelmed by the insurance company.

Melissa

Melissa I am around.   I am in Florida right now but have access couple times a day to the internet and computer if I can ward the nieces and nephews and grandkids off it long enough for me to check emails and messages lol

HELP!!

I'm finding roadblocks and I haven't even started yet.  I only have Medicare and I can afford the co-pays/deductibles.  I'm not sure I can afford to self-pay and why should I have to since I have Medicare?

I've contacted one office:  They require payment up front and then will bill Medicare for me.  I can probably do this but I really have no idea how much money they are talking about.

Another office is giving me incomplete information and will only tell me I can't come to their advertised seminars because I only have Medicare and that I will have to go on a wait list and I can't even find out what the wait list is waiting for?  A Medicare seminar?

I also can't find any support groups local to me.

I live between Asheville NC and Greenville and Spartanburg SC but would be willing to travel to Charlotte or Atlanta or Nashville.

Can you help me get started?  I am fairly sure I want the DS procedure.

Thanks Vicki,

Becky in NC