disappointed with quote/ insurance

I went in for a consult for a TT or LBL and the surgeon's office took pics and wrote a letter to my insurance co asking for a panniculectomy. I also have at least one hernia, probably two. Well the ins. approved the panni with in three days, I was shocked! I have MN comprehensive which is Medica. So the surg.'s office sent me a new quote with the reduction of $1196.00 which the ins co says they will pay for the panni removal. WTF! How can 1200 cover surgeon, OR time, nurses and all that? I'm very confused. I do have another appointment so I am going to ask him but, the lady in his office says the ins co never pays for a TT so they don't bother to ask for one. On Medica's web site they have guidelines for TT, not just the panni removal. Oh, the surg's office didn't mention the hernias in the request for approval.
I am wondering if I can try to get the FTT approval another way and bring the approval to the surgeon? Do any of you think it would be a good idea to bring a print out of Medica's TT requirements to the next consult I have with this surgeon and maybe see if they'll try? I really like his work and he comes HIGHLY recomended so I would like to stay with him. I just don't understand how a TT can be $7700 and 3 hour surgery and the Panni is probably 1.5 hours and only 1200 bucks. I realize there is the muscle repair (which I need from being MO and having 4 big baby boys) and the skin tighetneing above the BB and getting a new BB but, geez. Maybe I should just get the panni even though I really need at minimum a FTT. I'm so bummed and confused!

I would try to get them to revise the request to include the TT and hernia repairs particularly if your insurance will cover the TT.  However, you may have to change surgeons.  Some just simply will not put in for a TT because in some ways if they do and they are a network provider they then cannot recoup the difference between the contract rate and what they actually charge for the procedure.  A network provider cannot charge you for the difference between what I refer to as full retail and the contract rate, they have to write it off per their contract with the insurance. 

Red

I printed my insurence guidlines of what it takes for them to approve a pannislectomy  and i got documentations (medical records)  from all my docs rash  back pain  meds used etc, Then i told my doc office to submit this right along with the doc recomendation  for Pannislectomy. She told me they never approve  this and I told her I have to go by their guidelines and submit it this way  and it should work and guess what it worked, Alot of office workers do not spend the time submitting the proper paper work because 1 it would require them to go beyond the normal duties for getting insurenece approval and 2 they have no idea what your insurence requirements are to get approval. My advice is do most of the leg work for your plastics  or docs office and u be surprised how much u can get your insurence to pay for it Pannislectomy. My doc did amazing job, I am so happy with my extended TT aka pannislectomy. My doc did my wls and pannislectomy and hernia repair all for 2k for out of network charge, Well worth the price and let me tell u no plastic surgeon was not gonna be doing that price I am just lucky that Dr naik really cared about my over all well being . I am sure he could have charged alot more but he was about restoring my body to the best possible way he could. Please don't get me wrong I am no way thumbing plastic surgeons as alot of them do amazing jobs it just most office personal  see it as cosmetic and the office tone is usually just that, I mean u walk into their office they are very nice posh etc all the receptionist are wearing nice clothes not smocks  they look like they all had boob jobs TT etc and u go to my docs office that did my weight loss surgery and well u r in office of people who need surgery for many other things. The office I am going to have my boob job at is very nice posh nice couches  has water and cookies and nice music and of course promos of what services they offer u, Oh yeah I feel like I am at a resort etc but also I am paying  5 k for BA. I mean I know I am being inticed for services I mean come on who does not want to look like all models they show. I went to many plastic surgeons before deciding on who was gonna do my surgery and let me tell you  the zip code makes the difference of the price. Had a few quotes of beverly hills doc and I am thinking I live in good old  town bakersfield where lets face it we off the beaten  path of the LA mentality  that everyone has boob jobs. I live 2 hours away from  pressure of city life and guess what docs here do amazing jobs for half the price, Pays to shop around and look at the office furniture before u go in how do u think that nice furniture was payed for? I am a relastic person and plastic surgeons are about seeling u youth back for a nice price, I am just glad I had a good doc that saw I wanted my life back and saved me 1000's of dollars. Sure I could have gone for LBL and paid for it all my self I had the options and yes it was a gamble as some people I read on here had horror stories but I also had few friends that went to well respected plastic surgeons  and they had horror stories . I think u need to have 100% faith in your doc and I am alittle nervious  as I am having a plastic surgeon do my boob job but I have heard nothing but good things about him from his pts and that is why I went to him his pts sold me on him. I would start talking to people at the gym good place to get alot of info on TT  boob jobs etc. I have alot of people asking me who did your TT and alot were so shock that a non plastic surgeon did amazing job and I said why not he cuts opens lots of bellies each day for appendectomy hernia repair etc I think he knows how to use a scapel. My scar is fading nicely  imgaine that for a non plastic surgeon he closed me nicely and he used spaced  out staples and hand suture to keep me closed tight . I mean it would be nice to wait in waiting room with nice furniture but I will over look at his office decor. LOL If Dr shaw does amazing boob job I will tell people just that and if he did not I will tell them the truth, I am well respeced and work in medical community and alot of people respect what I have to say, I only go to the very best docs as I do my homework . Being a emt u really get to know who are the best docs. Sorry for being so long but bottom line do your homework, GOOD Luck
Lisa

Ok, similar story here.  I visited 3 PS's.  The first one is one at the same hosp where I had my GB done, I was referred to him by my GB program.  He said he would do an anchor cut tummy tuck without the muscle repair b/c insurance won't cover the muscel repair uless there are hernia issues which I don't have.  No problem.  I'm okay with that.

He recommends the anchor cut because of the way I carry my fat/skin.  IGreat, because I don't want to be left with this muffin top on top of a nice flat lower section.   tell him I want to make sure that part of the process is going to take care of these "handles" I have on my hips where my panni starts, he tells me yup they'll be gone.  Cool.  I'm excited.  He does this stuff all the time esp for GB patients and he and his staff know what he is doing.

PS #2 comes HIGHLY recommended from the GB program at the hospital where my husband works (which is MUCH closer to home for us).  As a matter of fact, he is the only PS that the GB surgeon (there is only 1 at this hospital) refers her patients to.  Great.  I"m excited, could maybe have surgery done closer to home and this would save us about $750 out of pocket expenses since I don't have to pay the co-pay if I have the surgery done at the hospital where my husband works.  Not to mention that its only 25 mins from home, not 2 hours which obviously has lots of benefits and since my hubby works at this hospital there are added perks there too.

I meet with PS #2 (already got an approval with ins w/PS#1 at this point), very nice, well educated, beautiful office (has obviuosly done well for himself) and I am very comfortable that he is an artist that takes great pride in his work and the outcome.  HOWEVER, he swears that insurance NEVER covers an anchor cut for a panni, that they will only cover a hip to hip and he also emphasizes that insurance is very strict about hip to hip being exactly hip to hip, no extension to deal with my handles where the panni attaches.  I leave feeling very discouraged.  And feeling like I'm gonna end up looking pretty monsterish if he strictly does a hip to hip as he describes it.  There was no way I was gonna go through this surgery and still have these freakin handles and a muffin top.

I call PS #1 to ask about the approval for the anchor, tell them PS #2 said ins never covers it, they tell me they request it and get it approved all the time just like mine.   I call back PS #2 to tell them indeed PS #1 did submit approval for an anchor cut and my ins. did approve it that way.  They again insist and this time the office managaer gets quite firm with me on their stance that they will not do an anchor cut for insurance b/c insurance will not pay for it.  I'm so confused at this point and frustrated.

All along I have had a surgery date scheduled with PS #1 (they scheduled me on the day of the consult for 4 weeks out assuming I would get insurance approval, which I got in 2 days!)

At the 11th hour, I decide to have consult with PS #3, again refered by my husbands hospital but this time from the VP of Surgical Services.  I meet with him, LOVE what he wants to do to me but that's because it includes all kinds of cosmetic extras like lipo and stuff.  Essentially he wants to do a lower body lift with belly, thigh. back lipo and muscle tightening etc.  I'm ecstatic!  But waiting to hear the price tag.......so we meet with his finance coordinator who delivers the big news.

DRUM ROLL PLEASE..........cha ching $12k plus.  Ok, I'm not totally freaked out because I know some of this will be paid by insurance the question is how much so I know how much I will have to pay, so this is how this PS operates.  His office wants you to pay the full amount in cash up front and then get reimbursed by the insurance company, ok I'm still listening just want to know what that reimbursement amount will be.  After going round and round with the finance coordinator who esentially can't tell me what the full amount of reimbursement would be my husband is fed up and I'm in tears.  And let me tell you, I'm not the type to break down like that.  She tells me over and over again that the surgeons fee is 4000 if I just have the tt done or 7000 for the LBL for the TT my insurance will reimburse them 1400 of the surgeons fee, leaving it up to me to pay the remaining 2600 but that was the only piece of the 12k figure they could give me for reimbursements.  But here is the problem with this scenario.  Doctors enter into contracts with insurance companies to accept certain preset or approved amounts for specific procedures.  (Like the 1200 you are being told about) Anything over and above that the surgeon has to eat.  For example, I have a panniculectomy and the surgeon bills the insurance  2k for his fee, but the contract is $1400 so the surgeon eats $600 (just an example)  the surgeon is not allowed to pass this $600 difference along to the patient, that is part of the contract with the insurance company.  BUT, saavy PS's like this one have figured out that if you add even just 1 cosmetic procedure which would be a self pay procedure you can then just roll that into the patients part of the fee.  Essentially this PS wouldn't even discuss the possibility of "just" doing a panni on me because then he had no way to bilk me out of money.  I mean really, how are you going to ask someone to pay you 12k up front and not be able to tell them within reason what they will get for reimbursement??  How is a patient supposed to make a decision based on that information?  His hope is that they pay up, they get reimbursed what they get reimbursed and the rest is not his problem.  That is just so wrong on so many levels and quite honestly it probably violates his contract with the insurance company.  He was even collecting the anesthesiologists and hospital fees DESPITE the fact that his office doesn't do the billing for those departments - WTF? Are you kidding me.  This AZZhole preys on the people who are at a point of desperation and that ****** me off.

So to make a long story even longer.  I went with my original PS way up North, got my anchor cut "panniculectomy" or tt w/o muscle repair depending on who you talk to.  He extended my hip to hip incision far enough to deal with my panni handles and I am as happy as a pig in...........

My advice, go to a PS that is somehow affiliated with a GB program, at the very least get 3 consults done and find out in detail what they will and won't do.  Revisit the hernia issue b/c the muscle repair sounds like it should be covered in your case. 

Good luck and don't have anything done until you are comfortable that you are getting what you want  and will be pleased with the results. 

Thanks for the replies! It's frustrating dealing with many different aspects that have to coordinate. I wonder if I talk to the surgeon if he'll submit for the TT. He does work with a lot of WLS people.

Jessie,

insurance does not cover "tummy tucks", that is a term to describe an aesthetic abdominoplasty. It gets used interchangibly  here with an abdominal panniculectomy, but they are DIFFERENT procedures.

Things like "inverted T" incisions, muscle tightening, umbilical transposition, liposuction, and extension of the panniculectomy posteriorly are things specifically differentiated in the definitions of these operations as outline by Medicare/CMS (the feds).  The limits and scope of these procedures has been carefully negotiated between our professional societies and CMS to clear up confusion when there was no way in procedural coding to distinguish panniculectomy & abdominoplasty. There are now 2 specefic identifiers for this, one (panniculectomy) which has a RVU (value unit) associated with it and one with zero RVU's (abdominoplasty) to identify it as cosmetic.  When you do a partial insurance coverage abdominal procedure or body lift, both codes would be submitted to identify the surgery and you would be expected to pick up any costs associated with the cosmetic CPT code.

If your surgeon is willing to go above and beyond that and not charge you for it, then great.  Hell, today I turn a 90 minute panniculectomy into a 3 hour abdominoplasty/mons lift because I was teching a resident how to do these procedures. Do not however expect it as what is covered by your insurance plan. The scenarios laid out and sensationalized in this post are actually very straight forward and transparent efforts by different surgeons offices to explain what exactly your financial obligations are if you want surgery beyond an abdominal panniculectomy.

I understand the difference between an abdominoplasty and panniculectomy but, what I don't understand is why there is such a huge difference in cost from one to the other. How can roughly $1200.00 cover the surgeon's fee, anesthesia, the nurses and any other costs for the panniculectomy? I couldn't even get a colonoscopy for less than that! I'm just trying to figure it all out!

It doesn't cover the full fee... it covers the portion of the charges that the insurance company will pay for that procedure.  For example: my panniculectomy (with 24-hr hospital stay) bill was close to $20,000(!) and the surgeon billed an additional $2000... what the insurance company paid was about $5000 and $1000 respectively.

The problem is that when you are trying to coordinate procedures (some covered by insuracne and some NOT covered by insurance), it can be tricky sorting out the finances.  Unless the facility and surgeon you use bills each procedure completely separately, so there is a clean break between the insurance paying for the covered service and you only paying for the non-covered service, you can end up getting screwed.  You cannot go into it having a situation where the total for 3 procedures is going to be, say, $20,000 (where, for example, the portion for the insurance-covered procedure might be $5,000) and having them only credit $2000 against the $5000 (and you get stuck with the remaining $18,000).  You need it set up so that you pay only the $15,000 for the non-covered services and the hospital and surgeon have to "eat" the $3000 on the covered procedure.

Lora

That helps a little. What a pain. I had a better "naked" self image when I was fat. Now I feel like I have the body of an old woman and I'm only 33! I don't even let my husband see my in the nude any more! How depressing.

You are not alone there. (just turned 34 here)

I have consult #2 on Tues. I too have approval for the panni removal only. I was told by a few people and the surgeon I am meeting on Tues, to only expect the insurance coverage to be $1500-3000.
 
Sucks!!