Getting Started

I was wondering if someone can help me on here.  I am new to OH and just have begun researching WLS.  I have been to the "insurance" message board and posted there, but haven't heard back.  I was wondering if anyone could tell me what I should request from my human resource dept at work as far as coverage goes.

I already have spoke to my ins. co. and they have already told me that the RNY procedure is covered, as long as I complete the 6 months requirement and meet their criteria for co-morbidities, which I do.  But, I did read on the message boards that I should not take the ins. company's word for it and do my research myself.  That is why I was wondering what I should ask from my HR Dept.

Do I need both a copy of our policy along with the "Requirements"?  I know all insurance is different, but I was told to do my due diligence on my own just incase.  Can anyone help?

The only thing I think you need to ask your HR dept. is if they have excluded WLS from their policy.

When I had United Health Care -- they covered WLS, but my employer placed a WLS exclusion on their policy.  Therefore, it wasn't covered.

Other than that, I'd go by what the Insurance Company says.  Also, the surgeon' offices are generally very knowledgeable about coverages.

Good luck to you.

You want the 2014 plan documents. Ask for the one that is likely dozens of pages, not the one that may be a PowerPoint deck of 10 or so pages. Tell them you need to see if a procedure is covered and want details on any restrictions you need to be aware of. I think ours was called the plan summary document. Once you get that, you may want to call your insurance company to follow up with any questions you have. The big document is essentially the contract between your company and the insurance company, so if you meet the criteria and all documentation is submitted in good order, you should have no problems with approval!

Good luck!

Laurie

Thank you for getting back to me, I really appreciate it!  I was wondering, because I already had my ins. co. send me the hard copy of what it looks to be a "Miscellaneous" General Policy Guideline.  I asked for the specific information I would need for weight loss surgery and/or obesity and that's what they sent.  The "Topic" that is listed is "Obesity".  Then it goes on to list "Indications and Limitations of Coverage".

Do you think this document is too vague being that it is listed under miscellaneous?  It is only 4 pages.  I will call my HR Dept. this week.  Thank you so much for your help.  I have heard from one of the surgeon's office staff that some patients get hit with a $30,000 bill!  I am amazed at that.  I have been told that the surgeon's office is also responsible for working or talking to an individual's insurance company to make sure the patient is approved before moving forward.  How scarey.

This is why this document is so important. You are looking for the document that explains, in writing, the specific criteria you need to meet to qualify for surgery. Mine contained requirements about being 18, having a BMI of 40 at time of submission, having documented MO by a physician for 5 years, be a covered member, etc. I am hoping yours says something about a BMI of 35 with comorbidities.

Once you get that, there should be no surprises and your surgeon's insurance coordinator can help you the rest of the way. At some point, you should receive a written estimate/statement of what you owe. If you aren't offered one, ask for one.

The only financial trivia that I encountered along the way was that the doctor told me to stay in the hospital for at least 24 hours after my surgery so that it would definitely qualify as an inpatient procedure. Apparently, insurance companies can change up the rules if less than 24 hours and shift you to an outpatient procedure which may change your financial obligation. They said that if the doc released me on morning rounds the next day, don't be in too much of a rush to leave. I stayed from Wednesday to Friday so it wasn't a problem.

Best wishes on your journey. I had a five month appeal and I learned way too much about how insurance works along the way. I hope that doesn't happen to you, and ask questions any time.

Laurie

Contact your insurance carrier & ask them to email/mail you a detailed statement of your bariatric benefits.

Hi!

Thank you for the reply.  I asked my insurance company to send me a copy of everything in my policy related to weight loss surgery and they sent me basically 3 pages.  It said, "Coverage for the medical treatment of  morbid obesity is determined according to individual or group customer benefits.

Then it goes on to list the types of surgeries available along with what is required, etc.  I have BC/BS PPO.  Do you think this document is not sufficient?  Should I still contact my human resource dept at work for more in depth descriptions or do you think I should word it the way you did, "Bariatric Benefits", when I call the insurance company back?

I just don't want to get hit with a $30,000 doctor bill!  Yikes!  I am not sure if I trust my ins.  I'm sorry.  I just am so confused on how to go about this.  Any helpful information you can send would be greatly appreciated!

Thanks

Ellen

I have Humana & they have a Bariatric Department. They sent me a Verification of Benefits. It details everything related to bariatric that's covered. In my opinion you should get a written copy of your actual benefits for Bariatric Benefits. I dont see why your insurance company can't provide you with that. HR can only give you a general benefit breakdown. You getting the information straight from the insurance company provides precise coverage relating specifically for you & eliminates the possibility of surprises after surgery because you already know what's covered.