Recent Posts

misspeachpie
on 10/18/12 12:06 pm - FL
Topic: Medicaid
Hey I'm a newbie. I haven't had a procedure done yet. My question is....I have been approved for Medicaid now what do I do. Please help. Thanks in advance.
noftessa0401
on 10/18/12 9:55 am - San Diego, CA
RNY on 12/27/12
Topic: RE: Question on 3 month option with aetna
Aetna just approved me after the 3-month regimen.  I enrolled in an all-inclusive program where I met with a nurse, doctor, and dietician weekly.  I just had to keep track of my physical activity - no one had to sign me in, watch me exercise, or anything else like that.  I just tried to burn 2,000 calories a week.   I was most nervous about the exercise portion of the regimen, however.

I have heard of people fulfilling this requirement by going to the gym and asking the front-desk people to sign that they were there.  Alternatively, you can keep a log of exactly what you do, daily, and then talk to your doctor and nutritionist about it at each visit.

Good luck.  That was the most nerve-wracking part about this whole thing.

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

Glow2254
on 10/17/12 1:13 pm - LA
RNY on 02/28/13
Topic: Question on 3 month option with aetna
I choose the three month option. I had my first appointment with the Doctor, I go see the nutritionist tomorrow. My question is: What is an excercise therapist. What or my options for this requirement? I looked unto getting a personal trainer, but that is to expensive. What did you guys do to meet that requirement?
Mrs. Glow    
noftessa0401
on 10/17/12 7:16 am - San Diego, CA
RNY on 12/27/12
Topic: RE: BCBS of ND. Frustrated!
Your thinking sounds right to me.  Have you called your insurance company to specifically ask them why you have a bill for $900?  Have you called the hospital?  I would ask them those questions.  Insurance is so crazy and confusing.  It is quite possible something was charged as being out-of-network, or there was a coding error somewhere.

Good luck!

HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"

M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)

Lindsay J.
on 10/15/12 3:23 am - Minot, ND
RNY on 09/05/12
Topic: BCBS of ND. Frustrated!
Ok, I have never had so many problems understanding an insurance companies break down of pay in my life. In FL with United Health it was clear cut and understood and no problems. I thought I had a handle on how BCBS did things but now I sit here looking at my hospital bill and it is a few hundred higher than I expected and what the hospital told me should be my final bill after calling insurance before surgery. If someone can help me out in understanding where my thinking is wrong I would greatly appreciate it.

My Maximum out of pocket according to the insurance company between Insurance and Co-Insurance is $1250.00.

My Insurance Deductable is $250.00/per family member (this only had 23.00 left to meet it when I paid my surgeons fee, then the co-insurance kicked in and I had to pay 10% of whatever the $3000 fee that was left which was $300.00 which I was told would go towards my co-insurance deductable and it did)

My Co-insurance deductable is $1,000.00/per family member (or no more than $2000.00 for the whole family). So the surgeons fee that I paid the rest of is supposed to go towards the thousand, now making the deductable I have left to cover before I have met my maximum out of pocket $700.00)

Now in this time between scheduling my surgery and having my surgery I have also been to my GP and had the battery of tests that my surgeon required before hand done, which I have recieved and paid bills for and in benefit explination notices from BCBS was told some of this also went towards my deductable making it even less to finish having to pay (totals about $75.00 more paid towardds co-insurance deductable.)

Now this is where I get confused on the situation. I bill from the hospital was $900.00, don't get me wrong I know that compared to what others have had to pay or are paying that this is great, however it is not what I expected nor what I was told to expect. According to what I was lead to believe is that once co-insurance kicks in I am required to pay 10% of my bills UNTIL I HAVE MET MY MAXIMUM OUT OF POCKET, which even though my math isn't fantastic (I am just doing the co-insurance here because reg. insurance deductable has been met) $1,000.00 - 300.00 - 75.00 = $625.00 of a deductable left to pay, so even though my 10% of my hospital stay is $900.00, shouldn't I only have to pay the $625.00 left to cover my deductable which would then have met my max out of pocket making everything else covered 100%? And on top of it I was just told by insurance that yes max out of pocket was met on both ends of insurance and co-insurance the dates of surgery and days of stay but my er visit 7 days later for what they thought was a blood clot is going to cost me $117.00.

So if someone can please explain where my thinking is wrong I would greatly appreciate it.

       



 

mharroun
on 10/11/12 8:10 am - Forest Hills, NY
DS on 11/06/12
Topic: Oxford United Health Care: 6 month documented diet?
 Im in the process of doing all the requirements needed to have the duodenal switch surgery and I cant get a stright answer on the requiremetns for insurance to cover my procedure.

Here is the current PDF:
https://www.oxhp.com/secure/policy/bariatric_surgery.pdf

I have a BMI of 58 and Sleep Apnea, GERD, and a hatal hernia... when i call oxford twice asking about it and I am told that I do not need to do the 6 month documented medicly reviews diet(seems like just phone support reading off the same paper i linked) .... but from what I read around and what the surgons office has told me that its allmost allways required...


The document reads:
1 . Class III obesity (BMI > 40 kg/m2); OR
2. Class II obesity (BMI 35-39.9 kg/m2) in the presence of one or more of the following comorbidities...; AND
3. (part about 6 month diet)

Since my BMI is over 40 does that mean I am excluded from the 3rd part? Thats what the  epresenatives have told me... and by boolian logic (TRUE or FALSE and FALSE) = TRUE.... 

I am hoping someone who has had oxford and a high BMI could tell if they had to get the 6 month documentation...




 
mzlaura
on 10/10/12 11:21 pm - Litchfield, NH
RNY on 03/05/13
Topic: Optumhealth by UHC choice plus ppo through?
Does anyone know how they are? I was assigned a nurse through them. We have already spoken. I was told i do NOT have to do a consecutive 6 months of supervised diet as long as i have had 6 visits within the last 2 years and i have. I've been following my physician and nutritionist for well over a year now and had that faxed to her. She said she approval process is relatively easy. My bmi is current 52 and i have ashtma, feet problems, sleep apnea, pre-diabetes, back pain, problems with absesses boils yuck due to rubbing skin, etc. She said i met all the criteria. My program requires sleep studies which i had already and at least 2 months of cpap therapy which i have also already completed. The process for my surgeons office is 4-6 months and my new deductible doesn't start until April 2013 =) i found this out yesterday. Also i have $5500 oop so far and UHC told me under my ppo plan once i hit the $7500 max oop they will cover 100% which means i won't have to pay my co-insurance granted surgery is before April 2013. At this rate with all i have done already as part of the requirements i may just make it.

And my center is a center of excellence as well as the surgeons and my company doesn't exclude WLS so how quickly do you all think i would be looking at for an approval? My bmi has been over 50 now for over 5 years and my sleep apnea was just diagnosed in July. I also had my gallbladder out last May,



HW: 401  SW: 297  CW: 200.8
RNY gastric bypass surgery on March 5th, 2013

  

ChristieTX
on 10/10/12 7:56 am
Topic: Anyone have PCIP, how long for approval?
I have PCIP through the Affordable Care Act, and it does cover weight loss surgery. I have completed the 6 month requirement for the medically supervised weight loss and my paperwork was submitted Monday (10/8).

Anyone else have this insurance and been successfully approved? If you were approved, how long did it take, and did you call them during the process to check on it?

Thanks!
myahsmommy
on 10/8/12 11:08 pm - OH
DS on 12/18/12
Topic: RE: BCBS NJ
Within the 12 months prior to the time of surgery, the member must meet all of the following requirements:
    1. Documentation of previous participation in conservative (non-surgical) weight loss program or diet program/plan (e.g., Weigh****cher, Jenny Craig).



This is the only part that trips me up.  I called the insurance company (for whatever that was worth) and all she would do to me is read the policy.  The same one I've read a million times!!  "All I can tell you is what the poicy says"....  Yep, heard that a dozen times. :)  Well, my information will be sent in hopefully this week. After that, i just wait. 
montana28
on 10/6/12 11:34 am - FL
Topic: RE: BCBS NJ
You can actually find the guidelines on your BCBSNJ website. just click on Providers and search for obesity surgery. I have copied some of what I found on their policy. You would always do best to call your insurance and ask. get them to send/email the info .
https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf


II. If it is NOT specifically excluded by the member's contract, surgery for morbid obesity (bariatric surgery) is considered medically necessary when all of the following lettered criteria are met:

D. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements:
    1. Documentation of previous participation in conservative (non-surgical) weight loss program or diet program/plan (e.g., Weigh****cher, Jenny Craig).

      [INFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.]
    2. Documentation of participation in an organized multidisciplinary surgical preparatory regimen in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions. The regimen should provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery.

    3. Documentation of pre-operative psychological evaluation provided by a licensed mental health care professional familiar with the implications of weight reduction surgery. (Please note that psychological testing is NOT included in this requirement.)
Jules
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