WTHeck !!! FRUSTRATED AND IRRITATED

Hi everyone

I had lap band surgery in 5/08.  my staring weight was 237 and my lowest weight was 183. I had regular lap band fills and still was concern about the slow weight loss. About a month ago I went in for a fill and had no restriction. went back in 2 weeks and No restriction. :-( My doctor ordered a flouroscope and low and behold I have so much scar tissue that my band cant tighten.  Need less to say Im inching up to my highest weight   I am currently 203 and steady moving up

 I am swollen , in pain, port stinging, and bruised from the dumb scar tissue over my band :-(

My doctor suggest that I have a revision to the sleeve. Problem is my insurance will only pay for removal   I spoke to my doctor and suggested since i'm "self Pay" can I just pay for the sleeve since I'm already under and opened during removal. He agreed and said that I need to speak to the insurance girl.....

She comes in and says the doctor charges 3000 for sleeve and hospital fee's are 9900 totaling 12900. I explained to her what he said about hospital fees. She says that it cant be done like that

 My question is  IF IM ALREADY UNDER AND MY INSURANCE IS PAYING FOR THE HOSPITAL STAY FOR THE REMOVAL  WHY SHOULD THEY CHARGE ME FOR HOSPITAL STAY AGAIN BECAUSE  IM SELF PAY!!!!!!!

I am a women of principle and I feel like if i've been your patient for 4 years and have came regularly for fills and visits and you have billed my insurance and made money off of me shouldn't you try to help save me money since im self pay.

 I have left messages and he hasn't called me back. I'm feeling slighted and like a have a dollar sign posted on my forehead !!!!

 

I AM FRUSTRATED AND IRRITATED

Why won't your ins pay for the sleeve. Do you have a once in a lifetime WLS clause?

 Unfortunately my insurances have changed. The new insurance has a exclusion for weight loss surgery.

ok So I spoke to my insurance and they said that hey would cover all Hospital fee's but I would have to pay for the sleeve. I called the hospital where I was getting it done and the lady says that  they cant break the price down like that  WTF,... I feel like they just want me to pay the 12900 and they are budging on ANYTHING. OH and BTW  my doctor still hasnt called me Back !!!

very frustrating,

so here is probably a reason why, when you have surgery it is coded, for how long, what was used etc.  if for example you go in for a band explant they need to bill or drs fees, anesthesia amount, time in the or, time in the recovery, medication for everything, post surgery sleeve xray swallow,  etc, so when your dr said he charges a certain amount that doesn't include everything else and it is almost impossible to separate that all it is not like when you are under they can just do anything you need and only charge surgeon's fees there are a lot more fees and i think that is what they are saying they cant separate....insurance is always a tough thing..(.I have had 3 different insurance companies in the last 12 years, BCBS, United, and Aetna (Aetna is the worse by far) I have had to go through 4 appeals, was able to demonstrate medical necessity and even with the wls exclusion i was able to overtun all the denials with multiple insurance co,  and to date i still have a wls exclusion)  can you attempt to appeal for a revision, so you can get your sleeve paid?

Could you get the approval from your insurance in writing? Maybe then you could just pay for the sleeve. They would code it as the sleeve and you're stay would be paid.

As another person explained, it is the coding.  Laws vary between states, some can get away with a different type of coding and some can't.

Your portion of the sleeve is about $5K more than going to Mexico for self pay.  ;o(

Can you check out another center/doctor?  My insurance would pay to remove the band for medical necessity but, I had to fight for the sleeve.

  Was there an exclusion on your policy?  How did you win?  What was the process? Thanks to everyone that's replying :-)  I really need as many suggestions as I can get. Im calling my doctor back today and making consultations with two others . Fingers crossed.

I had documentation of all the medical issues with the band.  I had testing and total unfil for 6 weeks a year out and for 8 weeks at 2 years out.  Every fill and unfill was documented.  The testing of course as they paid for it.  I could show I lost that first year before being unfilled.  I could show I had gained every time unfilled.  They agreed to pay to remove it based on medical problems.  Once they went in and removed the band, with the photo of how it looked after, they determined it was caused by medical problems and NOT non compliance.

My insurance had a once in a lifetime WLS policy no matter who paid for the original surgery.

I do know that some surgeons will do non covered work at the same time as covered.  Plastic surgeons can do the surgery while covered work is being done and just charge for the difference.  I, myself was researching getting the sleeve in Mexico in case the insurance here wouldn't cover it.  I spent months on the Mexico boards and felt good with a couple surgeons.  Than someone here gave me the info for the surgeon in Ohio and I could get the surgery here for not much more.  Once I was approved I blew the info away.  Sure wish I hadn't.  It was a lot less than 12,000.

That said, my center charged the insurance 40,000+ for the band and 60,000+ for the sleeve, so 12,900.would be a deal.