Question:
If i pay cash for my surgery, will my HMO pay if I have complications later?
My insurance company covers the surgery, but it is very strict in their approvals. My problem is I need 6 months supervised diet and I don't have that. With a BMI of 41, if I follow a diet for 6 months I'll lose just enough weight not to qualify, then once I regain (like most of us do)I'll have to start the whole process over again. HMMM. Vicious cycle. I decided to pay cash for the surgery but I can't afford to pay for three additional surgeries should I have strictures of other complications! Worried that I won't be able to pay and be left without a resource for treatment. Is this is a bad idea? Help please. Thanks! — denisel (posted on September 1, 2002)
August 31, 2002
I have Cigna and when I got my first denial letter, it stated I was free to
proceed and pay for the procedure myself, but Cigna would not reimburse or
pay any associated charges with such a procedure, so I'd guess they would
not pay. It's best, however, to check with your policy and see what their
liabilities would be.
— Cathy S.
September 1, 2002
Denise, Though I was approved by my insurance Co. I to had to provide past
diet history. I have tried every diet there is out there but god is only
the that truely knows when, how long and the weight I lost. I just knew if
I lost 10 pounds then 16 of his friends showed back up! I guessed there is
NO WAY for them to verify things like weight watchers, jenny craig, ediets
(online) etc. Try sumbitting a diet history (I have known people to use
others diet histories). Any of the Jenny Craigs (ETC) are sometimes
considered by Insurance as supervised! Give it a try... you really have
nothing to loose! I had my surgery 08/23/02 LAP RNY Medial and I am doing
great! I can't see why I waited!
Jessica in NM
— jessmessen
September 1, 2002
I paid cash for my surgery and everything went fine. I was worried about
having complications and ending up with a $80,000 hospital bill or
something. I was talking with a lady who works at the hospital about this
concern. She told me that if I had to be admitted again for a problem my
insurance would have to pay because treatment would be medically necessary.
I had my surgery July 11th and as the bills are coming in, I've found that
my insurance (who REFUSES to pay for this surgery) is paying for certain
parts. They paid some to my surgeons, to radiology, to anesthesia, and a
couple of other things. Of course, they didn't pay anything towards my
$32,000 hospital bill. But I didn't really expect them to. I figure that
at least I'll be healthy in 40 years when I finish paying the hospital! =)
Good luck to you!
— Tanya B.
September 1, 2002
Who says you have to "stick" to the dr. supervised diet. My
insurance co wanted the same thing, and the only thing that they were
looking for was documentation on my dr med records that he was monitoring
me once a month for 6 mos. I simply had to go and weigh in, they noted my
"non weight loss or a pound or 2 of loss" and then I went on my
merry way...Sometimes you have to play their games for a few months to get
them to pay and it sounds like that is what you are going to have to do.
They're playing games with you asking for 6 mos supervised diets..that's
just a "put off ploy for them"..so they can make you wait for 6
mos.Beat them at their own game.....
— Joi G.
September 1, 2002
I'd do their "diet" as there is no way they can watch you to know
what you do or don't eat. Eat what you want and say you are eating what
they tell you. As far as if you self pay, then later have problems. It
would be "medically necessary" so they would have to pay. I've
found that you have to play their stupid games. I had to have councelling
in order to have gender reasignment surgeries. Believe me, you HAVE to PLAY
THEIR GAME. I don't like lying, but sometimes there is no way to get out of
it. Unfortunatly you can't always get through this life by being honest.
Sad but true.
— Danmark
September 1, 2002
I have a friend that self paid. SHe was a revision and had numerous
complications following her surgery requiring her to be in the hospital for
numerous weeks following the surgery. Her insurance company did not pick up
any of the charges from the prolonged hospitalization. IN addition, she now
needs a hernia repair, which the insurance has also denied as being related
to the original surgery. I do not know what insurance she has, but find out
how your insurance would handle these things if they come up. My friend is
now in bankruptcy.
— Vicki L.
September 1, 2002
I would appeal the HMO's decision first before concidering self pay. It is
quite possible that they will not pay for anything other then an emergency
room visit. It becomes a very sticky situation when dealing with an HMO.
They hold the cards and control the medical care decisions. You may even
consider changing insurance. It would be cheaper to do that then to pay out
of pocket.
— Sue A.
September 1, 2002
See the Doc and meet the insurance rule, but DONT loose any weight. Just
put in the 6 months. Then let insurance cover you. they are doing this to
try to save money, hoping you loose interest... We really should organize
to get WLSA covered by law everywhere. I wonder ifd this could be done on a
federal basis?
— bob-haller
September 1, 2002
Denise, I was in your situation earlier this year. My HMO required one-year
of supervised dieting with their nutritionist, their doctor, their
psychologist, and their group exercise program. If you weren't deemed to be
"compliant" (i.e., if you didn't lose weight as expected), then
they wouldn't approve you for surgery. If you lost weight and no longer
qualified based on BMI, then they wouldn't approve you for surgery. For
"lightweights" like me, it was a Catch-22! I decided to go ahead
and self-pay rather than doing their program. My HMO
"officially" won't pay for complications that are a direct result
of a non-covered surgical procedure, but so far, they've been pretty
good... including covering one out-of-network ER visit, CT scan, and
overnight hosptialization when I became dehydrated about two weeks post-op.
They've also covered my post-op blood work so far. Also, when I mentioned
to my primary care doctor that the HMO had said that they wouldn't cover a
late complication such as a bowel obstruction, she said, "I'd like to
see them try to tell ME that." So, if your HMO has a written exclusion
for complications following non-authorized procedures (most do), then it is
a definite financial risk... but one that I was willing to take. I didn't
see much other choice, if I wanted to have this surgery. People who have
non-covered plastic surgery do this all the time... they just cross their
fingers and hope for the best. Good luck with your decision!
— Tally
September 2, 2002
Another big factor is in billing. Once the surgery is over and done with,
there won't be any billing for "obesity-related services." When
I spoke to my doctor's office about insurance billing, they told me that
any further services performed would be for treatment of "chronic
malabsorbtion" (I think that's what they called it) This means that
any strictures, stoma problems, etc. would be covered because it is no
longer a treatment for obesity, it's a treatment to ensure you get the
nutrition your body needs. I wish you the best of luck with your struggle
with the insurance company and with your surgery!!
— Laura S.
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