Question:
How do I begin the approval stage with Medicare?

I have Disability Medicare (FL) and I would like some advice on how to begin my journey. Should I contact the surgeon first or my regular Dr. What happens if my Dr. is against WLS? Please give me any information you have! Thanks!    — Lynette C. (posted on April 11, 2003)

April 11, 2003
I just had the surgery in Wash. and my dr. told me that medicare does not pre-approve procedures, you have the procudeure and then see if they are going to pay, and that if they do you are responsbalbe for 20 percent of the unpaid balance.And that it has to be medically necessary. I went to my primary dr. first then on to the surgeon. I just got my hospital bill yesterday, but havent' heard anything as of yet. Good Luck
   — Wendy T.

April 11, 2003
I am on Medicare disability in MN. The first thing I did was research WLS. When I knew what I wanted to ask for, I checked out all the surgeons in my area (on this site and others) and the hospitals. I called to set up an appointment with the surgeon and then I called my PCP and told him what I was planning. (Luckily, he was delighted.) Before I had my first consultation, I made a complete list of all the medications I take, a list of all the professional people I see (home health care, nurses, doctors, case manager, therapists, etc.) with names, addresses, and phone numbers, a complete diet history (estimated times, kind of diet, treatment programs, etc) and a list of all my comorbidities. His office sent out some paperwork which I filled out, and brought everything to the appointment. The surgeon specializes in the kind of WLS I want and has priviledges at the hospitals I trust. His office is obtaining letters from my PCP, therapist, and eating disorder therapist telling him that they believe that I am a good candidate for WLS. He then told me that I will need to get an upper GI and a gallbladder ultrasound before the surgery. They will send all the paperwork in to my insurance (Medicare and Medical Assistance). When I am approved, I will be scheduled for support group meetings and a surgery date. In the meantime, I am doing my best to lose some weight before my surgery. I still gather as much info as I can about what I need before surgery, what other people experienced with their surgeries, and what to expect afterwards. I hope this is helpful for you. Good luck!
   — Judy K.

April 11, 2003
check out my profile...it covers this subject in detail.
   — jennifer A.

April 11, 2003
Try to find a surgeon and hospital that accepts Medicare Assignment. This means that all they get paid is what medicare pays them and they can't come after you for the twenty percent. All you have to pay is about 400. deductible for the doc and 800. for the hospital. My best friend just had this surgery and medicare worked this way for her. You don't have to get pre-approval. As the other posters said, research the surgery, find a doc that will take ASSIGNMENT and leave the rest up to them. My friends PCP was not even part of the loop. She found out after the fact as did mine because our surgeon has his own team of nutritionist and internist that clear you for the surgery as far as your co-morbs go. Good luck. Oh, I forgot, my friend did not have to pay the money up front. They billed for it.
   — Delores S.

April 12, 2003
Hi Lynette I also have medicare due to disability. I'm scheduled for surgery in May. As some of the other posters have said, the medicare process for this surgery seems to almost be easier on some level, then battling some of the HMO's. If fact, I recently had an HMO tied into my medicare A and B, and had the HMO portion removed, solely to make this process easier.I will ultimately be responsible for things like medications and other items not covered by medicare down the road, but I will be able to have my surgery without prior approval. The previous poster is correct in finding a DR that accepts medicare assignment. I found my DR (who is a top surgeon in the field of weightloss and still accepts medicare), and the Dr's office has done an amazing job doing everything else for me.I was even told, "you concentrate on preparing yourself mentally and physically for the surgery, we'll handle the insurance issues!" They put together the package that includes all of my other health issues, psych eval, BMI, any test, etc..and submit it to medicare AFTER my surgery is complete. This concerned me, because i didn't want to be caught responsible for the cost if they didnt pay later. I was assured that due to a BMI higher than 40, and other contributing health factors, it wouldn't be a problem. I will only have to pay a portion of the DR's charges, as well as the $800 dec from the hospital later. (I've set up a payment plan for this in advance). If youre unsure, medicare also provides a help hotline where you can call and find out exactly what procedures can be covered. If you call their 800 number, they will transfer you to the correct dept for medically covered policy issues. I started looking into the surgery in Feb with my first DR appt, and could have choosen to have had my surgery in April. The process went VERY quickly. Good luck to you!
   — Goodgirl

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