*****ally Wants the 6 month programs

After many calls, online chats and emails, I have the impression that TriCare is not making the structured 6 month Weight Loss Program part of the requierments, but the surgeron is!!! I think his purpose is to put money in his pocket.  His office is pushing their program and won't tell me any way that I can meet the requirement, ie Weigh****chers or my PCP. Since he knows TriCare doesn't they won't pay...so his office tells us it's TriCare s$400 flys out of my pocket!

Good am,

I'm sorry you are having issues with the surgeons office you've chosen. If you are not getting what you want from him/her maybe you should consider finding another one. You may want to consider questioning the surgeon/office in person. I wish you the best!

I agree with what Kat said and would like to add from an insurance point of view (I work for one of the major companies in the US)..most of them DO require the six month WLP.  The surgeons office also may require this.  Just call the insurance and ask what their requirements are.  If you are unhappy with the surgeon, now is the time to discover that.  Not just weeks before your surgery!  Good luck.

It really depends on where you are going for care. If you are being treated at a military hospital you can get approved before the 6 month diet, but you end up on a structured diet for 6 months while you are on the waiting list anyway. And YES Tricare DOES require a 6 month weightloss plan before getting approval for surgery. there is no way around this other then the military hospital's barriatric program. good luck.

christy

My insurance didn't pay for my surgery at all, so I don't know what their requirements were. I waited 3-4 months to have my surgery, however so that I could do it over the summer when I was off (I'm a teacher). My surgeon suggested, but didn't require, a supervised program at a nearby office designed for WLS patients during that time.

I met regularly with a trainer, nutritionist, "life coach", and doctor. My insurance paid for parts of it, but I ended up paying about $1500. I hated every minute of it, too But I ended up being really glad I did it - post-op life was still a huge change to get used to, but it was easier because I had already made many changes in my life. I lost 27 pounds pre-op in the 3 months that I was there and really think that it has made me more successful as a post-op.

I haven't continued going there since surgery, however. (I just can't afford it!)

Having said that, if you're not comfortable with this surgeon find a new one! You're not only letting this person rearrange your insides , but you will be following up with him for a long time to come. You will have lots of questions and you need to feel like you have someone that you trust to go to with them.

The results of my battle today:

Marla,
I have communicated with the insurance company from the customer service, to
Medical Management to the Policy Divison TMA West a Mr. Bob Bassey.  I have
been assured that TriCare DOES NOT REQUIRE A STRUCTURED WEIGHT LOSS PROGRAM!
This seems to be from the surgeron, Ruth has given me some info that should
meet the requirement, but I will not use your service for that. Once I am
into my program I will follow up on the next steps for surgery with your
office.  I do wish you and the team had been more honest about who was
making the requirement.



Their response:

Hello,

Because of your (and other Tricare Standard patients)concerns about criteria
requirements for Tricare Standard, I've called and spoken with our Healthnet
representative. After a lengthy conversation she states there has been a
re-review, and although they recommend the 6 month WL program, clearances
etc. we(Dr. Halmi) are no longer required to make our patients comply.  If
they (Tricare Standard patients) so choose they may proceed as desired with
the minimum of having a BMI of 40 with the knowledge that medical necessity
is determined at the time the claim is review.

We can schedule your surgery at any time, providing that you are willing to
sign a waiver that states you are aware there is no pre-certification
process and may/may not be responsible for your bill.
 
At no time are we dishonest with our patients as that is certainly not good
business practice. As you can see I've also made Marla aware of your email.

Ruth

I LOVE TO WIN!!!!!

Glad you got it straight but coming from an insurance standpoint...be careful.  It may just come back to bite you in the a$$.  If no precert is given you can be held responsible for the entire bill.  Ask for a voluntary precert to be done in advance of having surgery for your protection.

I'm glad you got the answer you were looking for. the 6 month diet typically refers to the PCP. They are not "supposed" to refer you without this 6 month diet...some do...mine at a Military treatment facility took my word that I'd been using Weigh****chers for 8 months.

It seems that you are self referring to the surgeon so perhaps you are Tricare standard. In this case you wouldn't need the referral. Good luck.