Frustrated already with the WLS center - Page 2 - ThinnerTimes

BabyNicole · 07-18-2008, 03:28 PM

Quote:

Originally Posted by jenn75

Puddin - yes, you make a good point and I do appreciate their approach at preparation. I guess I didn't appreciate that they gave literature showing that you had a choice between their approach and choosing your PCP's approach. my PCP has done this with many people, so I just feel very comfortable with her guidance. but i know that the WLS center is also a center of excellence so I should also trust in them, i just don't yet because of all of the mixed info i've received thus far. it's nothing against their intent of their program.

BabyNicole - yes, I'm aware that I'm now below the 40, I have sleep apnea, as well as depression and GERD. after I lost some weight, I tried to go without my c-pap machine, hoping that perhaps the sleep apnea had corrected itself, but alas, I still have it, so I'm still wearing that lovely machine at night still

.

Okay, hon, but still be careful. I had the best insurance (I didn't even need authorization, 6 months diet, etc.) and they didn't accept sleep apnea as a co morbidity. Are you positive your insurance company accepts that as a co morbidity? Mine only accepted: diabetes, cardiovascular disease, hypertension, and joint disease. I also have GERD and depression, but that wasn't on their list.

jenn75 · 07-18-2008, 09:16 PM

If I call the insurance company, will they tell me this straight up? Or will they not tell me this until the actual formal denial?

I will say that the insurance I have is also the same name as the WLS center. This may not mean they are one in the same, but I do think they have a LOT of people who go to their center because they have my insurance because it will pay 100% as a preferred provider. I do think they most likely base a lot of the practices based on the insurance requirements of this major insurance carrier. This being said, the WLS center has stated that sleep apnea falls into the category of a Major Comorbidity, which is what the insurance carriers look at for comorbid criteria, and that the GERD and depression are looked at as minor comorbidities, that probably aren't considered, especially if the BMI is on the lower end.

Anyway, I will not assume anything. I will certainly call the insurance company and ask them if they are going to tell me the criteria they use. I was not sure they'd tell me this. I actually work for an insurance company, actually, the same company of the insurance that I have, but I work for a different entity that manages medicaid for behavioral health benefits, so I do know nothing of the physical health side of things for my insurance. I know well enough that there is the actual medical necessity criteria that we follow and that everyone, including our members, are privy to, but that is rather vague. Then there are the "behind the scenes" things we use to help guide our decision-making. I will say no more, but let's just say that it helps us narrow down possibilities and clinical scenarios a little faster and clearer. We would never tell our members these things...it's just for internal use.

Thanks for asking me these things, though, because I don't want any surprises down the road. I'm trusting my PCP to guide me through this. I trust that she knows what she's doing. She's stated she's never had a denial, so I feel I'm in good hands, but she's worked with another WLS center mostly, so this is new territory for her, too.

BabyNicole · 07-18-2008, 11:25 PM

Quote:

Originally Posted by jenn75

If I call the insurance company, will they tell me this straight up? Or will they not tell me this until the actual formal denial?

I will say that the insurance I have is also the same name as the WLS center. This may not mean they are one in the same, but I do think they have a LOT of people who go to their center because they have my insurance because it will pay 100% as a preferred provider. I do think they most likely base a lot of the practices based on the insurance requirements of this major insurance carrier. This being said, the WLS center has stated that sleep apnea falls into the category of a Major Comorbidity, which is what the insurance carriers look at for comorbid criteria, and that the GERD and depression are looked at as minor comorbidities, that probably aren't considered, especially if the BMI is on the lower end.

Anyway, I will not assume anything. I will certainly call the insurance company and ask them if they are going to tell me the criteria they use. I was not sure they'd tell me this. I actually work for an insurance company, actually, the same company of the insurance that I have, but I work for a different entity that manages medicaid for behavioral health benefits, so I do know nothing of the physical health side of things for my insurance. I know well enough that there is the actual medical necessity criteria that we follow and that everyone, including our members, are privy to, but that is rather vague. Then there are the "behind the scenes" things we use to help guide our decision-making. I will say no more, but let's just say that it helps us narrow down possibilities and clinical scenarios a little faster and clearer. We would never tell our members these things...it's just for internal use.

Thanks for asking me these things, though, because I don't want any surprises down the road. I'm trusting my PCP to guide me through this. I trust that she knows what she's doing. She's stated she's never had a denial, so I feel I'm in good hands, but she's worked with another WLS center mostly, so this is new territory for her, too.

Yes, you def. need to call your insurance company. Ask them what the exact requirements are regarding BMIs and co morbidities. Also ask if there are any exclusions to WLS. Get the person's first name and last initial (some won't give their last name), date, and time you called. That way if there are any questions, you can refer back to that same person.

Now, at my surgeon's office, they also considered sleep apnea to be a co morbidity, but as I said, my insurance did not. Also, just because "so and so" got approved and has the same insurance doesn't mean you will too. Many companies (that you work for) write in their own exclusions as to what they will allow their employees to get. That's why it's imperative that you call them or visit them online if you can.

Good luck! And I didn't mean to worry you.

jenn75 · 07-21-2008, 02:53 PM

Thanks for the tips. I decided that I would use the online message feature of my health plan so that all of the responses I get will be in writing already. I can print them all out to have them on file. I just sent them my questions about the BMI and comorbidities.

jenn75 · 07-21-2008, 06:48 PM

Update: I got an answer, an answer that I, personally, am not surprised to get.

Their answer is that I will need to undergo a series of tests first. Then my doctor should know if I should qualify in order to start the authorization request process with them. Approval is decided on a case by case basis. And if I don't like their answer then I can file an appeal.

The three questions I asked were pretty specific:

Are there any specific requirements I must have in order to qualify for the surgery? Is there a minimum required BMI? What comorbidities are considered that could qualify me for the surgery?

LizzieShell · 07-21-2008, 07:11 PM

My insurance company had the requirements for WLS right on line.

It was very specific as to what was needed, including a 5% weight loss in the 6 months before surgery. It also have all of the other requirements & co-morbidities listed for both bypass and lap band

I printed mine out so I knew what was expected...

your company may have something similar

jenn75 · 07-21-2008, 09:05 PM

Quote:

Originally Posted by LizzieShell

My insurance company had the requirements for WLS right on line.

It was very specific as to what was needed, including a 5% weight loss in the 6 months before surgery. It also have all of the other requirements & co-morbidities listed for both bypass and lap band

I printed mine out so I knew what was expected...

your company may have something similar

No, their website doesn't provide anything related to criteria about any procedures. I think they rely on the provider to know what the criteria is, not the member.

scoman187 · 10-25-2008, 08:11 PM

Quote:

Originally Posted by BabyNicole

Yes, you def. need to call your insurance company. Ask them what the exact requirements are regarding BMIs and co morbidities. Also ask if there are any exclusions to WLS. Get the person's first name and last initial (some won't give their last name), date, and time you called. That way if there are any questions, you can refer back to that same person.

Now, at my surgeon's office, they also considered sleep apnea to be a co morbidity, but as I said, my insurance did not. Also, just because "so and so" got approved and has the same insurance doesn't mean you will too. Many companies (that you work for) write in their own exclusions as to what they will allow their employees to get. That's why it's imperative that you call them or visit them online if you can.

Good luck! And I didn't mean to worry you.

I called my insurance company to find out their requirements for RNY...They were kind enough to send me a 22 page description of the necessary steps. The 22 pages covered all the Bariatric Surgeries not just the RNY. I showed it to my surgeons office and they gave me their requirements list to compare and make notes.It helped alot. Im preop myself. I jumped through hoops.I feel it will be worth it. keep on em....dont let em forget ya in the mess on their desks. ...Sco'

jenn75 · 10-25-2008, 10:24 PM

thanks for the info. i have already switched weight loss centers. i have to updgrade my current insurance package (=higher insurance cost out of my paycheck per month next year) so that it will pay for more than just 70% at my new WLS for the actual hospital/surgery stuff, but it will be worth the switch. i've already completed my 6 month supervised diet w/ my pcp, i've completed all pre-op testing, and really i'm just waiting for my pcp and psychiatrist to get all of the paperwork in and my surgeon's office to let me know that they've submitted to the insurance co. for approval process. i will have to wait until january for the surgery because that's when my insurance plan changes will take effect, but they told me once i'm approved, which could be within the next few weeks, i can pick my monday in january!

it is becoming a reality!!! and it was so much easier and the staff so much more helpful at my new WLS. they always call me back and have guided me every step of the way.