Question:
I need help! I don't know how I should get started!

I just got insurance for the first time in a very long time. I don't have a PCP. The last doctor I saw was a few months ago, but that was @ a walk-in clinic for a worker's comp thing (I sliced my finger on the job and it need to be looked @) Other than that, the last doc I saw was when I was pregnant. My daughter is now 6. I don't know if I need to find a PCP first or if I could just make an appt. to see a surgeron. I have Aetna Open Choice PPO, if that helps. I have been obese my whole life. No matter what I do nothing works permently. I need to change my life for myself and my family. I just don't know where exactly I should start. ~~ Thank you in advance to anyone who replies    — barkingspydr3 (posted on March 23, 2006)

March 23, 2006
Have you got a book of providers and policies from your insurance co. or employer? If so it should state in the handbook, if not then I would call my insurance co. and ask them what process you need to go through. My insurance co. is making me go through 6 months of working with a health coach and dietician before I can start the process of having a gastric bypass. Good luck to you. Tanya
   — Tanya1992

March 23, 2006
Hi Myra, i would first find a PCP and start there. I then would check into your insurance and make sure that they do cover it. In the mean time you can be talking to your PCP about your weight and make sure you find out what requirements your insurancehas... for instance do you have to see a doctor for weight loss for x amount of months etc. you can get that started now
   — drunyan

March 23, 2006
Aetna PPO you can self refer. Go online and find a surgeon in your area thats in your network and make an appoitment. Also Aetna has 'strict' guidelines for qualifing; which you can also find online to be sure you have them all.
   — star .

March 23, 2006

   — [Deactivated Member]

March 23, 2006
Hi Myra, I think it is very important to have a PCP. Mine has been very involved in my WLS process. He has helped in so many ways. He has refered several other patients and he has kinda been a guide for me of sorts as to which way to go next. Most insurances require that you have a letter of recommendation from your PCP as part of the approval process. You should definately check into that to see what is required and if your insurance even covers WLS. That will save you alot of unecessary back tracking. You will more than likely need copies of medical record for the past 5 yrs. It may not be a bad idea to go ahead and request those. But definately call your insurance company first! My surgeon required that. They need to insure that either your insurance covers it or that you have an alternate method of payment before they start this enduring process! There is alot of leg work so be prepared, but it is all going to be worth it in the end! Good Luck!
   — jbailey

March 24, 2006
Hi Myra- I have Aetna- and a few mos after my surgery- we switched to Aetna PPO- I think it means you dont have to have a referral by your PCP to see a specialist- if that is your plan- you can see a WLS surgeon (research them) and choose one. Aetna usually does not pay for the first office consult.But don't let this stop you. Surgeon's usually provide a list of physician's they recommend because you have to have a series of tests completed before surgery- they can also recommend a PCP. ( I did this with my surgeon-and the PCP is still my PCP and I love him) He was already familiar with the surgery & the process- I DID NOT have to convince him why I wanted it etc- he already understood- AND when Aetna required 6mos of weigh ins (they require it) we counted it from the first office visit.. he ultimately makes the recommendation to your surgeon for surgery- and he completes the Letter (as required by Aetna) to your surgeon- listing all your previous attempts at weight loss. If you do not have ANY weight loss medically documented in the last 2 yrs- You will have to do 6 mos of "weigh- ins". Its not a big deal.. But keep in mind- you dont have to lose weight- even if its a total of 10 lbs ( some patients gained weight on it) Aetna wants it documented you tried ..If you lose TOO much- they will deny your claim..If you dont have the 6 mos of weigh ins- they will deny your claim. And Aetna is notorious for denials.. so keep this in mind..see the surgeon- He can tell you better than anyone- what each Insurance company requires and what surgeries they will approve ( RNY v. LapBand). This changes every January- as the insurance companies modify their policies.. Last year- before my surgery- I was talking with Aetna- and they were talking about "exclusionary policies".. (Mine was not one of these but became one in Oct'05) THIS MEANS- they exclude surgery like RNY by policy coverage- and you then have to talk to your Human Resource person.THAT'S how tricky Aetna is becoming. So do not wait untill Jan'07.. I would begin today and I would also give Aetna a call and see if your company policy has one of these "exclusions"..then it would be up to your HR administrator whether you have coverage- and can take up to another year for them to modify the policy. Do not be discouraged..Insurance companies just do NOT want to pay for this surgery- and you just have to navigate past them and get it done ASAP..the sooner you begin, the sooner you can begin feeling healthier. Good luck! Donna
   — nybabe

March 24, 2006
Hi Myra- I have Aetna- and a few mos after my surgery- we switched to Aetna PPO- I think it means you dont have to have a referral by your PCP to see a specialist- if that is your plan- you can see a WLS surgeon (research them) and choose one. Aetna usually does not pay for the first office consult.But don't let this stop you. Surgeon's usually provide a list of physician's they recommend because you have to have a series of tests completed before surgery- they can also recommend a PCP. ( I did this with my surgeon-and the PCP is still my PCP and I love him) He was already familiar with the surgery & the process- I DID NOT have to convince him why I wanted it etc- he already understood- AND when Aetna required 6mos of weigh ins (they require it) we counted it from the first office visit.. he ultimately makes the recommendation to your surgeon for surgery- and he completes the Letter (as required by Aetna) to your surgeon- listing all your previous attempts at weight loss. If you do not have ANY weight loss medically documented in the last 2 yrs- You will have to do 6 mos of "weigh- ins". Its not a big deal.. But keep in mind- you dont have to lose weight- even if its a total of 10 lbs ( some patients gained weight on it) Aetna wants it documented you tried ..If you lose TOO much- they will deny your claim..If you dont have the 6 mos of weigh ins- they will deny your claim. And Aetna is notorious for denials.. so keep this in mind..see the surgeon- He can tell you better than anyone- what each Insurance company requires and what surgeries they will approve ( RNY v. LapBand). This changes every January- as the insurance companies modify their policies.. Last year- before my surgery- I was talking with Aetna- and they were talking about "exclusionary policies".. (Mine was not one of these but became one in Oct'05) THIS MEANS- they exclude surgery like RNY by policy coverage- and you then have to talk to your Human Resource person.THAT'S how tricky Aetna is becoming. So do not wait untill Jan'07.. I would begin today and I would also give Aetna a call and see if your company policy has one of these "exclusions"..then it would be up to your HR administrator whether you have coverage- and can take up to another year for them to modify the policy. Do not be discouraged..Insurance companies just do NOT want to pay for this surgery- and you just have to navigate past them and get it done ASAP..the sooner you begin, the sooner you can begin feeling healthier. Good luck! Donna
   — nybabe

March 24, 2006
Hi Myra, The first thing you need to do, is call Aenta and find out of Weightloss surgery is covered under your plan. If it is, you can go to Aetnas website @Aetna.com look under their Clinical Policy Bulletins, and it will tell you what they expected you to do. Look under O When you get into the Bulletins. It will be the first one(CPB) 0157. I have Aetna also. I Did not go through my pcp. I just found a Surgon That I was comfy with and gathered all My medical records from 20 years back. I had my surgery Mar 17,2005, am down 104# Fill and doing great. Good luck
   — toledotink

March 24, 2006
Find a Gast.Bypass Surgery support group in your area -- attend as many meeting as possible. They will tell you which dr they had, also lots of other very informative information. If you get close to the end of the year, and have not been scheduled for surgery, just get all your pretest done before the end of the year just in case your insurance changes.
   — tweazee

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