Where you ever approved through Tricare? If so what did they require? I am wondering as I am also going for a referal today. PS: I am Tricare Prime.

The $30,000 is a lifetime pre and post ma cap.  It applies to all related procedures as well.  Hopefully I will talk to the doctors office today.  .....This is just so frusterating

I have the state health plan (NJ Plus) and my surgeon was out of network.  For his patients, he works with those who are in network ans well as those who are out of network.  I am pretty sure for most physicians they overbill insurance companies for patients who are out of network in order to get paid the same amount of money as in-network patients.  I did have to pay out of pocket but not a lot (seriously, it wasn't much and you can PM me for the exact number).  

Your surgeon might not want to discuss specific numbers but maybe he can explain how payment works and what you will be responsible for and what you won't be responsible for.  I think most surgeons or their staff will explain to you what is possible and not possible depending on your health insurance plan.

What I would watch out for are a couple of things:

I know your health insurance company said there is a $30,000 max cap but is that just for the actual procedure or does that also apply to related procedures as well (i.e. endoscopies, lifetime blood tests, complications from surgeries).  You want to find that out now so you don't get stuck with a huge bill later.

I know it seems like your insurance company is really limiting the procedures available to you but don't let cost determine which procedure you will have done.  Any WLS procedure is meant to be a lifetime procedure so you don't want to do one procedure due to cost only to later regret it.  I know that is easier said than done but while revisions are possible, I can't imagine why you would ever want one.

 

I was denied twice by my insurance co.  On each denial, I wrote an appeal letter addressing exactly what they had spelled out as their reason for denial.  I had to take it point by point.  In my case, each instance they had one reason for denial so it was fairly simple to respond to that.  Basically you parrot their language a little bit.  Like when they said I had not been compliant with the 6-month doctor supervised diet, I replied I had followed the criteria set forth by my doctor and nutritionist's plan but I was unable to maintain the very low calorie diet plan due to my large volume stomach capacity.  In my doctor's office, we had to keep a diary of everything we ate, calculate the calories and an exercise log.  When that was presented to the insurance company on the first submission it's like they pistol whip you with that information so instead of getting mad and giving up (OK, I was mad & emotionally wrecked at first but I put on my big girl panties & fought back), I humbled myself and said (in my appeal) that this doctor's supervised diet was yet another example of a failed diet attempt and that the RNY surgery is what I felt was the best choice to help me in controlling my hunger thru reduced capacity.  I also listed all my health issues and how daily life was difficult for me.  You really have to put yourself out there in these appeal letters.  Defiance & threats won't work.  If you have met the insurance qualification criteria they have no choice but to approve you.  It's a hard and rocky road for some of us.  I really feel they are just trying to get people to give up.  Those that do simply means they don't have to pay out anything and therefore that money is in their pocket.  It takes a lot of medicine & dr. visits to accumulate to a $65k surgery (what my surgery would cost without insurance).  And we know these insurance companies are in it for the money, not because they truly want you to have a better quality of life.  Sad but true.  Hang in there girl.  If you are denied again and want help answering, contact me again.  I'll be glad to help if I can.

Check out the website for the insurance commissioner in your state.  There may be information on the site, such as a sample grievance form that you can use as a "go by."  If not, give them a call and see what they suggest.  The second source you can consult is the insurance company's own website.  They should have information for their insureds on how to file grievances and/or pursue appeals (also check any denial letter you received; I have Aetna, and they clearly state how to appeal a decision in the letter itself).  You might also ask your surgeon's office if they have a sample you could use, as I'm sure they've had other patients who have been in similar situations.

Try to make your grievance clear and concise, and be prepared to include any copies of medical records, etc. that show your BMI.  Good luck to you!