Well after talking to many offices this is what I was told. Since my insurance wants me to do a 6 month med. supervised diet and my PCP isn't all that interested this is what I have to do. My WLC offers a weight management program at my assessment for the program I asked if this was suppose to be for my 6 month diet, the answer was no it is only a 12 week program. Today they told me yes it is for the diet. I first do the 12 weeks which a nurse and the gym keeps track of me. Then I do another 12 weeks where the gym only keeps track of me and that those 12 weeks there is a $50.00 out of pocket charge. I don't mind this but I have to go Tue and Thurs. nights for 6 months and I can't start it until I have a stress test. So I was lucky and got an appointment with my heart doctor for tomorrow afternoon but don't know how soon I can get the test done. It looks like this might take me until Jan or Feb before I can get the surgery. P.S. For all of you that was able to do this with your PCP you were lucky.
I'm so glad you finally got a resolution. It's just a shame your PCP doesn't care more about the overall health of a patient and that it will cost you money out of pocket, it shouldn't be that way. Personally I would start looking for a new PCP, ubt that's just how I am.
Your insurance will count that, if only the gym keeps track of you? It does not need to be a physician supervised diet? Are you sure?
Please note: I AM NOT A DOCTOR. If you want medical advice, talk to your doctor. Whatever I post, there is probably some surgeon or other health care provider somewhere that disagrees with me. If you want to know what your surgeon thinks, then ask him or her. Check out my blog.
I hope they are right according to what I could find out from the insurance company it has to be in a primary care setting and this place is. There is a certified clinical nurse specialist there but I don't know if she is there for the second set of 12 weeks. There is certified people there that report back to the nurse. During the time there I am suppose have one hour of nutrition and one hour of exercise. Then the second set it is just the exercise. If I go through this and the insurance company comes back saying it isn't going to count I hope I find out before the surgery since they don't pre-approve the surgery. Then I will be responsible to pay for the surgery. I think it should be easier than this. I've already spoken with the insurance company many, many times all I get is if we pay and we can't say we will. So I might get stuck with a huge bill and that really scares the crap out of me.
I know that you have already talked to a LOT of people about this, and the last thing you want to do is make yet another phone call, BUT...
I would strongly suggest that you make one more phone call to the insurance company to make sure you get a direct answer to the question about whether a 12-week diet supervised by a "clinical nurse specialist" rather than a physician will count AND whether 12 weeks of diet classes and 12 weeks of exercise classes would count as 24 weeks of supervised diet. My guess is that if you lay it out that clearly to the insurance company, they will say "no" to one or both of those questions.
I'm not sure what you mean that it is a "primary care setting" if it is not supervised by a physician (I would expect that when an insurance company says "primary care setting" they are expecting a PCP or GP to be supervising and I would be very concerned that your insurance isn't going to accept it.
Have you asked the surgeon's office if the surgeon will see you once a month and supervise the diet? (That is who did mine.)
Another phone call seems like a small price to pay to avoid having them refuse to pay for surgery after the fact (yikes!) because they say you didn't meet the the 6-month diet requirement! (if they don't pre-approve surgery, you are VERY unlikely to find out that it doesn't qualify before you have surgery).
10 years out; 190 pounds lost, 165 pound loss maintained
You don't drown by falling in the water. You drown by staying there.
As Lora suggested - make sure you confirm with the insurance. But IMO - get it in writting. I see tyo many posters that goit info on a phone but they had no proof in writting about the conversation. I personaly woulksd not risk it, I would find new PCP.
Hala. RNY 5/14/2008; Happy At Goal =HAG
"I can eat or do anything I want to - as long as I am willing to deal with the consequences"
"Failure is not falling down, It is not getting up once you fell... So pick yourself up, dust yourself off, and start all over again...."
I am so glad you got this solved. It is aggravating when your PCP won't work with you. Mine PCP was supportive but he kind of made me made because he wrote on my PCP approved letter about not seeing me for 2yrs because I went to another Dr for those 2 yrs. But he fails to remember he was my main Dr through all my weight problems.
Think of it this way.....it's going to take six months regardless of where you do it or with whom.
Due to a leg injury, I was required to repeat my six months, along with every clearance, before my surgery.
Then, my surgeon had an immediate family member who was terminally ill and I was delayed another six months.
im now five months out! have list 85 lbs and don't even think of the delays.
I don't regret the delays as I was able to gather more information, knew more clearly what I was facing and went I to surgery totally prepared for what followed.
Use your time to educate yourself on all aspects of your procedure and what your requirements will be post op.
Before you know it, you will be talking about your post op experiences.
Did you ask your insurance if they would consider any other programs as a medically supervised weight loss diet? My insurance accepted both Weigh****chers and Jenny Craig. Granted, this would cost you more than $50, but you'd only have to go once a week and wouldn't have to deal with getting a supervised gym program. My surgery center had my nutritionist supervise me for 3 months but when the insurance wanted 3 more months, they accepted my previous Weigh****cher receipts that I had gone to prior to my nutritionist. I was able to get surgery the next month. Suggest you look into it.
Thanks everyone for the advise and your replies. I am going to keep calling the insurance company and I am seeing the nutritionist again on Tuesday so I am going to ask her if my appointments with her count because the insurance did say a certified nutritionist can supervise me. They said a PCP, Certified nut. nurse pract. a reg nurse or any doctor in a primary setting our outpatient hospital. This exercise program for at least the first 12 weeks is supervised by a reg. nurse. But I think I am going to ask the Nut. if I can see her once a month since I already seen her last month I would think that would count. If I does I will not do the second set of 12 weeks. Why should I pay? I did find out that Jenny Craig, Weigh****chers, Nutra system doesn't count if it did then I would have it already. I also am seeing my heart doctor today and am going to speak with him about this. He was the first one to recommend this surgery. I wi**** would be a simple as getting a different insurance but that won't matter because I am disabled I still would have to use my primary insurance which is Medicare. I think agreeing to the Medicare insurance was the worse decision I ever made not just because of this but for other reasons.