X-post One last shot - with a doc not on list
If you read my previous post, after losing 240 pounds, I was approved for thigh skin removal (thighplasty), only the doctor of choice refused to run Medicare for Prior Authorization, as did several others.
Last ditch is a local doctor my PCP recommended against, perhaps because there was some controversy surrounding office staff embezzling him and comitting insurance fraud in the news at the time.
I've contacted the surgeon with my body and insurance issues. They're supposed to get back to me today. The outcome could be no different that the others.
I suppose I really don't have a choice, and anything is better than nothing. I've also made an appointment for some counseling, as I need to begin dealing with possibly living with a lifelong disfigurement, as well as some grief issues, as I just buried my Mom April 23rd a day after what would have been her 93rd birthday.
Last ditch is a local doctor my PCP recommended against, perhaps because there was some controversy surrounding office staff embezzling him and comitting insurance fraud in the news at the time.
I've contacted the surgeon with my body and insurance issues. They're supposed to get back to me today. The outcome could be no different that the others.
I suppose I really don't have a choice, and anything is better than nothing. I've also made an appointment for some counseling, as I need to begin dealing with possibly living with a lifelong disfigurement, as well as some grief issues, as I just buried my Mom April 23rd a day after what would have been her 93rd birthday.
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
I read your prior posts and they confuse me, I don't understand why you can't just contact Medicare and explain what you need to have done and find out what the doctors need to do to make it happen. If the surgeons are willing to take your Medicare insurance then don't they bare the risk of not getting paif if Medicare refuses, not you?
Please help me understand.
Please help me understand.
Edited to add: I did contact Medicare, and it's the same process I went through - with no issues like this one- to get my DS approved. The difference is, unless it's medically necessary, which this surgery is documented as being, Medicare does not pay for *any* type of "cosmetic" surgery. Because of the infections from the loose skin, my surgery is already documented as medically necessary. It's the billing and insurance people at the doctor's offices who are refusing to put in the paperwork to get prior authorization, which is the same thing as approval. For me, and most private insurances, prior authorization is *required* before *any* type of surgery.
I am not a reconstructive surgeon, or physician of any kind. The surgeons need to write letters telling them that yes, this is a medical need, and this is what it's going to take to do it right.
Prior authorization for this kind of surgery is based on medical opinion. My opinion or request means nothing to the insurance comapny's medical review board. The problem is finding a surgeon that accepts Medicare and/or Medicaid. In any surgery, the patient guarantees payment if the insurance doesn't pay.
It has to be medically necessary, which, due to the number of skin infections and cellulitis (subQ fat infections) I've had, it is. Fabric of a medical compresson garment (heavy duty ACE bandage material) to hold the skin still causes abrasions, which has led to the infections I've had.
I don't have extra money lying around to pay for this surgery. I am on Social Security Disability. If I did, this wouldn't even be an issue.
This is the last piece of surgery before I can continue Vocational Rehabilitation and get off of disability, with a viable profession. I also have Systemic Lupus Erythematosus and Fibromyalgia, which precludes my former occupation, and is what got me onto disability in the first place.
My Voc-Rehab counselor advised me to complete all surgeries before resuming my coursework. The surgery I need is not a three week healing process. It is likely closer to three months before I will be able to do what I need to do.
I don't have a family. I'm single with no kids, and I just buried my Mom April 23rd.
Bottom line: my weight loss has left me with a bonafide deformity, which also has a negative impact on my health, hygiene and ability to return to self-sufficiency.
It's the insurance and billing clerks at the doctor's offices who are refusing to do the paperwork, based on other patient's cases, not mine!
I am not a reconstructive surgeon, or physician of any kind. The surgeons need to write letters telling them that yes, this is a medical need, and this is what it's going to take to do it right.
Prior authorization for this kind of surgery is based on medical opinion. My opinion or request means nothing to the insurance comapny's medical review board. The problem is finding a surgeon that accepts Medicare and/or Medicaid. In any surgery, the patient guarantees payment if the insurance doesn't pay.
It has to be medically necessary, which, due to the number of skin infections and cellulitis (subQ fat infections) I've had, it is. Fabric of a medical compresson garment (heavy duty ACE bandage material) to hold the skin still causes abrasions, which has led to the infections I've had.
I don't have extra money lying around to pay for this surgery. I am on Social Security Disability. If I did, this wouldn't even be an issue.
This is the last piece of surgery before I can continue Vocational Rehabilitation and get off of disability, with a viable profession. I also have Systemic Lupus Erythematosus and Fibromyalgia, which precludes my former occupation, and is what got me onto disability in the first place.
My Voc-Rehab counselor advised me to complete all surgeries before resuming my coursework. The surgery I need is not a three week healing process. It is likely closer to three months before I will be able to do what I need to do.
I don't have a family. I'm single with no kids, and I just buried my Mom April 23rd.
Bottom line: my weight loss has left me with a bonafide deformity, which also has a negative impact on my health, hygiene and ability to return to self-sufficiency.
It's the insurance and billing clerks at the doctor's offices who are refusing to do the paperwork, based on other patient's cases, not mine!
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
If you have medicare coverage and they say they will do the surgery and bill medicare and they think its gonna go through, why would you think it wouldn't? If you are on disability and have no money for them to get from you how can they expect you to pay for this? I still don't understand, your last post confused me even more, so much so I wasn't sure how to even respond. If you can find a doctor who accepts medicare and confirms you have a problem that is covered by medicare then that should be enough, right? I self paid my plastics and had to prepay. What do you think they can take from you if you have nothing to take and why worry about it until they come trying to collect?
If there is no guaranteed form of payment (insurance or cash), I get no surgery. If Medicare does not say in advance "yes, we will cover this", I get no surgery. The problem is no one will even *ASK*, by doing a prior authorization, even though they say they accept Medicare as insurance. It's a subtle way of getting rid of patients who don't have the resources to pay.
I don't have the cash to pay, since I get less in social security disability in a month $1,605, after Medicare premium, than a high school grad would earn sacking groceries. My working salary was three times that monthly.
I have a BA, which is worthless now, since I cannot return to my former profession. I have Systemic Lupus Erythematosus and Fibromyalgia. My job was very physical. Sacking grocieries is very physical, and knee problems prevent standing for long periods, otherwise, I would be sacking groceries!
I am training for another profession. My Voc-Rehab counselor says I need to complete ALL MAJOR SURGERY before continuing my program. I am 54 years old, so I don't have a lot of time to continue to qualify for retraining.
I hope that clears it up for you.
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
I think the confusion is... If u were approved, isn't that medicare saying yes, they'll pay?
What's the difference btwn an approval and a pre-auth?
Hope u get it all straightened out! GOOD LUCK
What's the difference btwn an approval and a pre-auth?
Hope u get it all straightened out! GOOD LUCK
HW:344 SW:329 CW:207.8 Losses: pre-op - 15/ post-op - 121.2
M1 - 25 M2 - 18 M3 - 14.2 M4 - 11.8 M5 - 14 M6 - 9.6
M7 - 6.6 M8 - 7.0 M9 - 5.6 M10 - 7.8 M11 - 1.6+ M12- ??
Pre-auth is the process where you present your case, and they approve or deny coverage.
Medicaid and Medicare are two different programs.
MedicAID, which approved the surgery, is a federal program based solely on income, and is run by each state. They approved the surgery, but they are basically my "supplemental" insurance. They won't pay anything until I spend a certain amount out of pocket. When I had my DS, They paid for transporation to and from my hosptial for the 6 months of mandatory pre-op support group attendance.
MediCARE which is my "primary" insurance- is the federal program providing health insurance for seniors and the disabled. This is the insurance that the doctors I've contacted say they accept, but then they refuse to run prior authorization on,saying Medicare "rarely" approves the surgery I need. I have already talked to someone at United Health Care, which admnisters my AARP Medicare Complete plan, and they say if it is documented as medically necessary, they do pay, but the issue is getting that through the skulls of these doctors and their insurance and billing people!
I think the issue is that while Medicare and Medicaid pay, they pay far less for the procedure than a cash patient, or even some private insurance would pay, therefore, they find a way to weed me out as a patient.
My next step, while I'm seeking another surgeon, is to seek a lawyer to fight this unfair proactice of economic discrimination.
Medicaid and Medicare are two different programs.
MedicAID, which approved the surgery, is a federal program based solely on income, and is run by each state. They approved the surgery, but they are basically my "supplemental" insurance. They won't pay anything until I spend a certain amount out of pocket. When I had my DS, They paid for transporation to and from my hosptial for the 6 months of mandatory pre-op support group attendance.
MediCARE which is my "primary" insurance- is the federal program providing health insurance for seniors and the disabled. This is the insurance that the doctors I've contacted say they accept, but then they refuse to run prior authorization on,saying Medicare "rarely" approves the surgery I need. I have already talked to someone at United Health Care, which admnisters my AARP Medicare Complete plan, and they say if it is documented as medically necessary, they do pay, but the issue is getting that through the skulls of these doctors and their insurance and billing people!
I think the issue is that while Medicare and Medicaid pay, they pay far less for the procedure than a cash patient, or even some private insurance would pay, therefore, they find a way to weed me out as a patient.
My next step, while I'm seeking another surgeon, is to seek a lawyer to fight this unfair proactice of economic discrimination.
HW 405/SW 397/CW 138/GW 160 Do the research! Check the stats!
The DS is *THE* solution to Severe Morbid Obesity!
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