Surgery: From fast track to on hold
Long story short, I've been working towards my RNY since last summer. My position was eliminated 12/31, so I opted for COBRA insurance (choke) to the tune of nearly $700 a month for individual coverage, knowing I was having surgery in Feb. Well, between my employer and the insurer, they didn't get coverage for Jan/Feb straightened out until about a week ago, and coverage was retroactive, but that delayed approval. I've jumped through the million hoops of fire--6 mo. medically structured weight loss, monthly doctor visits, an array of mental health tests/counseling, visits to the nutritionist 3x and bariatrician 3x, surgical consult, pre-op, all labs w/chest x-ray/abdominal ultrasound/EKG. Every box was checked according to my bariatric clinic.
Surgery is supposed to be next Tuesday, and I called to verify that everything was in place. (I had to call the insurer, only because the clinic was closed due to a huge snow storm in Minneapolis). What I thought was a formality, turned into a nightmare! The rep said they denied the surgery yesterday, as they only have weights from 2013, and they want to show I've been obese 2+ years. I told her I have been morbidly obese by medical definition since i was probably 2 years old (52# on my 2nd birthday), and that I didn't think I'd even gone to a doctor in 2012. I eventually spoke to a supervisor, and she said that any appeal will likely be denied until I can prove 2+ years. When I offered documentation from Dec 2012 (the last time I could find that I'd seen a doc prior to Jan 2013), she said it was too old. I'm at a total loss, and in tears.
I'm on day 11 of a liquid diet, and don't want to give up over the weekend in hopes that the clinic person can push through some kind of medical appeal, and yet I am frustrated beyond belief.
on 2/21/14 5:51 am
I hope things get cleared up soon, I am afraid of that happening to me I have switched to cobra/cigna as of February 1 and was told there is no difference between requirements for surgery under cobra since I still have the same ins just have to pay 110% for coverage now yikes?hope to get approved and have surgery before the end of March.🙏
Anyway I hope the ins person at your surgeons office will have so pull and that you are able to keep your original surgery date.🙏
I can't afford COBRA month after month, so I've applied to MNSure (MN version of the Affordable Care Act). Because my unemployment hasn't kicked in due to a glitch (comedy of errors--I worked for the state, got laid off, and another branch of the state couldn't see that I'd ever been an employee). Anyway, with $0 income, I qualified for Medical Assistance (again, MN version of Medicaid), and it says that bariatric surgery is covered if there are co-morbidities. My biggest fear is that I will have to transition insurers, and that I also have 2nd round interviews scheduled for two jobs, so who knows WHAT insurance I will have in the upcoming month(s). If Blue Cross keeps fighting me, I'll just ask my clinic which of the others is easiest for THEM to work with, and hopefully get MA to pay for it in March, and if I get a job offer, delay it by a few weeks. I don't know which piece of stress is the bigger puzzle piece at this point...looking for work, or trying to get the surgery done while toughing it out on the liquid diet, LOL.
That sounds like a nightmare. Sorry to hear you're dealing with that so close to the surgery date. I would think the Surgeons office should have known about the 2 year weight requirement sooner. My office knew exactly what I needed prior and made me aware of everything at my first visit.
Good luck...I hope you get this worked out.
Surgery date: 2/17/14
I don't know if this will help you, but I was missing weights for 2012 too. My insurance requires 5 years (count them, FIVE!) of BMI over 35, plus comorbidities, of which I have plenty. My coordinator suggested I submit dated pictures from that period, so I did. I guess since my BMIs from 2009, 2010 & 2011 were >35, and my BMIs from late 2012-2013 were >35 my insurance accepted that. I don't know anything about COBRA, but I would call the insurer directly and ASK if you could do this.
Thank you--pics are a good idea. While I avoid them like the plague, the few I do have, clearly show I've been "more than pleasingly plump" for quite some time. I'm also going to try to talk to the bariatrician and the surgeon Monday morning, and I am writing an appeal letter this weekend. Basically, it will say, if you do not approve the RNY for Tuesday, I will still go ahead and have my gallbladder removed that day due to stones. Then, you will have the added expense down the road of a second surgery, surgeon fees, hospitalization, anesthesiologist, etc. It's your choice to have it done all at once, or to pay double in the end. Meanwhile, I'm sticking to my liquid diet in hopes that this can all play out. *sighs*
What a day! I wrote a heartfelt letter to the insurance, combining my reasons for needing the surgery, with basic lifelong obesity...52# at 2, 174# by 10 yrs, haven't been under 300 since 1990, have a Bi-pap machine on a very high setting (worse than C-pap) and have reduced oxygen or stop breathing an average of 124x/hr if I don't use it (yes, that's about every other breath). I pulled together 10 pics--one from when I was 22 months and 50#, and the rest from the last 6 years, all clearly showing me aging and growing in size, and that I've yo-yo'd the past few years. Nonetheless, my BMI is clearly around 50 by most of the photos. (Thanks for the idea, mustlovepoodles!) I'm thinking the insurance folks just don't want to do the surgery on people who are right on the 35 BMI bubble, as I've heard from others here and on other sites that some people actually try to gain weight to qualify for the surgery--imagine that! For me, Monday can't come soon enough. I'm hoping that between the pics, the letter, and maybe my clinic insurance rep and the surgeon pushing a few buttons with a supervisor or two at Blue Cross, they can convince them to let me move forward with Tuesday's surgery.
on 2/22/14 12:30 pm
OK first and foremost, I think that you should leave it to the people who verify insurance and specialize in dealing with your bully of an insurance company! They are obviously being blithering morons because it makes no sense you need proof of obesity for 2+ years and yet proof from 2012 is too old. Secondly, have you looked into Obamacare? I was definitely not a supporter of the health care program, but since we have it use it! You can qualify for up to $0.00 premiums based on income! it's a sliding scale! That's what i did! I am getting the surgery and I had ZERO hurdles! All I had to do was go to a doctor talk, a support meeting, a psych consult, and a nutrition class. Boom! That's it!!!! I have health net. Don't call your insurance carrier! It's just going to confuse and frustrate you! (I work in the work comp insurance industry TRUST ME it's daunting! Keep your chin up and don't give up! You have done a lot of work to get to this point and I am sure the doctor's office wants you to have the surgery too and they know just who to talk to and what to say to get this approved!
on 2/22/14 12:34 pm
Oh and sidenote, I pay $480.00 a month by doing this! Which is about $150.00 more than through work. But doing the math, i will still only spend $2,000.00 or so on a $30,000.000+ surgery! I opted out of my work insurance program because they completely blocked any kind of WLS! I make a lot of $ though and I live and work in California! I hope you look into this and I wish you the very best of luck!
I applied on 2/15, and because my unemployment hadn't kicked in, due to a severance, and I had $0 income, I have Medicaid for March. I just haven't gotten the paperwork. The day I do, I will send it in, and hope they set me up with an account # ASAP. Then, on Mon. 3/3, hopefully the clinic can send in a prior auth and get things rolling. Meanwhile, I have a couple second round job interviews coming up, so my next little dance will be if one offers a job, and the surgery is still pending. Sighs!