Confused again

So here I am again confused what else is new. I have to do a 6 month medically supervised program. The clinic I went to for the pre-surgery has a weight management program which consist of education on nutrition and exercise. The clinic says this counts for the 6 month program. So the back of the pamphlet say contact your insurance company because it might not cover everything. I was on the phone with them 2 times this morning. Once asking them if it would be covered and the second time with codes and they do pay for some. But they kept reading back to me what I had in front of me. Which is they cover 1 meeting each week for 1st month then 1 every other week for months 2-6. The clinic I went to wants me to go 2 times a week for 12 weeks then I'm not sure if I have to repeat that again or what happens. As often as I have asked them they keep reassuring me that their program IS the 6 month program. My insurance also says that it is preferably done by my PCP or any other kind of doctor setting office. I just don't want to get stuck paying for all these appointments if I use the center that is doing the surgery. I have also read that if you have one appointment per month with say a nutritionist, and another with a NP, and another with the surgeon then that will equal 3 months right there. All this insurance crap confuses the heck out of me. And then to top it off the don't preapprove the surgery. I have to have it done and then find out if they pay, but like someone said they wouldn't do the surgery if they thought they wouldn't get paid so I'm good with that. I tell you I just can't wait until I don't have to deal with the insurance company anymore. Any suggestion would be welcomed.

A 12 week program is not a six month program.  It sounds like the program your clinic offers is not the same as what your insurance requires.

I know that's what I thought but I've spoken with them many times on the phone and every time I ask if this is the program I need for my 6 month supervised plan and every time they say yes. For people that need more than 12 weeks they said they can continue with them, at home, or at the local YMCA. So I guessing that they will have me do another 12 weeks that would equal 6 months. I guess I will have to go and see if I get billed for any of this usually my insurance will pay x amount and my other insurance will pay the rest. If I have to pay then I think I will go to my PCP since the insurance company gave me guide lines for my PCP. I'm only considering the clinic because they are the ones doing the surgery. I even read some where that if you see your doctor one month, then the NUT another month, that would count as two months towards the 6 month plan. I think basically they just want to monitor your weight but not positive this is why I get so confused. Every time I talk to the insurance companies I get a different answer.

Usually for most insurance companies, people just see their PCP once a month for the six month diet.  I doubt your insurance is going to pay for you to go once or twice a week to six months.

That is what I thought too. I thought if I go for one month then get the bill see if the insurance company is going to cover it if not then go to my PCP. I think I might just call the NP back and ask her what I'm suppose to do. But I'm not sure I liked her to much. She was kind of snotty in the beginning but when I left she gave me a hug.

What your clinic wants and what your insurance will pay for are two separate things.  I had a 9 month supervised diet requirement by my insurance.  I went once every 30 days to my PCP.  It was covered as a doctor's visit.  I was told numerous times that I didn't need a primary care physician apt if I had a NUT appointment, group diet counseling or visit with the bariatric surgeon or internist.  I STILL KEPT my PCP appointments every month.  I didn't do any group/meetings etc that weren't covered by insurance.  Long story short: I was approved first submission.  Two other people in my "group" with the same insurance who used the clinic's apts. had to submit two and three times.  In my experience, multiple appointments in the same month DO NOT LESSEN THE TIME REQUIREMENT.  Of course, YMMV.  

Six months means six full calendar months, and you generally have to see the physician each of the six months and then -- for Aetna insurance, at least -- you must see the doctor a SEVENTH time, because the first visit is when they deem the program to have started, so to have completed six months, you have to have the extra visit.

I'm a little confused by your statement, and not sure if this is what you are saying people have told you, but having a dietician visit, a physiologist visit, and a physician visit all three in the same calendar month is still one month, not three.

Does the surgeon's office require that you do THEIR program, even if your insurance doesn't cover it?  Is the 6 month diet a requirement for the surgeon or just  y your insurance?  If it is not required by the surgeon, why not just have your PCP give you an eating and exercise plan and do that for 6 months?

Unfortunately, some surgical offices have figured out that they can make a lot of money by "requiring" programs like the one you described (and they know that most insurance won't cover it, so most patients have to pay the full fee for the services (instead of the negotiated amount that the insurance company covers).

Is there another surgeon in your area that you could use?

Lora

Hi thanks for the advise. I know that the 3 people I saw doesn't mean it would count as 3 separate times. While I was searching for help I did come across a statement that said if you saw one person each month then it would count as 3 months however even if that statement is true and I'm not saying it is it wouldn't count for me. The confusing part for me is I am beginning to think that my insurance wants one thing and my surgeons office wants another. I know what the surgeons office want would also count as my 6 month program as long as I do it for the 6 months. But if I go to my PCP it wouldn't cost me anything and at that I would have to go once a week for 1 month then once every other week for months 2-6. I can't get any where with my insurance company. When I tried to explain to them about the program at the surgeons office I did find out they would only cover some of the cost. When I talked to the surgeons office and told them what the insurance office requires I got well your PCP isn't a exercise program is it. I know that if I did go to my PCP we would talk about exercising but is it an actually exercise program no. But the insurance just wants to know if I talked to my PCP about what I'm eating and what I'm doing for exercise and that she checked my weight and blood pressure. I know it's a lot and that is why I'm so confused. But I agree I think sometimes the surgeons offices make up things just to get more money. I could go into Boston which is a bit of a ride where as the office I'm using is just down the street. And other than this 6 month thing and  the pre-op and the surgery itself I have all my other appointments all ready set up. But thanks for posting I've been able to work through some of this mess with different post. I'm sure it will all work out even if I have to pay.  

Yes, what your surgeon's office wants is a different thing than what your insurance wants.

Does your surgeon require you to do their program?  Or is it just optional? 

I would tell the surgeon's office you plan to do the six months with your PCP, which is accepted by your insurance.

I was wondering about the required diet too...

My policy reads, "Active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months."  

I saw surgeon on 4/14

PCP diet appt on 4/23 

PCP diet appt 5/15

Planned PCP appt 6/13

Planned PCP appt 7/11  (4th visit)

My surgeon's office insurance biller says that is 4 visits and that is fine, but it's not really 4 full months...   

Anyone know if this sounds right?