ksk Posted May 28, 2009 Report Share Posted May 28, 2009 So I'm off to OCC next week and I'm trying to figure out how to proceed with follow-up care with my insurance once I get back to good 'ol NY. Do I have a better chance of 1) my insur covering 80% of an out of network doctor with fills NOT done via Flouro but done in the office (where it may be “coded” as a visit?) Or 2) do I see an in-network doctor & only pay the co-pay for the visit and then have the fills done under Flouro at a covered Hospital BUT not knowing if my insur will cover ANY part of the fills b/c initial surgery was not covered???? (and I'm assuming if done at covered hospital, the hospital will code the fill in a way that may send RED flags to not be covered...) Ahhhhhhhhhhhhhhhhhhhhh!!!!!!! WHAT TO DO?!@#$%^ Link to comment Share on other sites More sharing options...
Lindsay Posted May 28, 2009 Report Share Posted May 28, 2009 So I'm off to OCC next week and I'm trying to figure out how to proceed with follow-up care with my insurance once I get back to good 'ol NY. Do I have a better chance of1) my insur covering 80% of an out of network doctor with fills NOT done via Flouro but done in the office (where it may be “coded” as a visit?) Or 2) do I see an in-network doctor & only pay the co-pay for the visit and then have the fills done under Flouro at a covered Hospital BUT not knowing if my insur will cover ANY part of the fills b/c initial surgery was not covered???? (and I'm assuming if done at covered hospital, the hospital will code the fill in a way that may send RED flags to not be covered...) Ahhhhhhhhhhhhhhhhhhhhh!!!!!!! WHAT TO DO?!@#$%^ all of us are self-payers. i have yet to see an insurance company pay for the surgery, and fills. it doesn't qualify. Link to comment Share on other sites More sharing options...
ksk Posted May 28, 2009 Author Report Share Posted May 28, 2009 Thank you - Yes, we are all self-payers ( . However, that may be for different reasons: some have no insurance at all OR you may have insurance, but don't qualify for the WLS... For those who do have insurance, I was wondering what was the most economical way to proceed after the WLS with follow-up care, fills & adj... Maybe I wasn't clear - My apologies! Link to comment Share on other sites More sharing options...
Dolittle Posted May 28, 2009 Report Share Posted May 28, 2009 Thank you - Yes, we are all self-payers ( . However, that may be for different reasons: some have no insurance at all OR you may have insurance, but don't qualify for the WLS...For those who do have insurance, I was wondering what was the most economical way to proceed after the WLS with follow-up care, fills & adj... Maybe I wasn't clear - My apologies! As far as I know,, once you go down the path of self pay,, or you have no insurance coverage,, you will have to pay for the fills yourself. When I tried to get my insurance to pay for the lap band, my employer had no WLS of any kind written into the policy. Which ment that any aftercare wouldn't be covered too. I don't know of anyone who had to self pay and then got their insurance to cover fills. If they did,, I'd like to know how they got it done. Link to comment Share on other sites More sharing options...
Clynn Posted May 28, 2009 Report Share Posted May 28, 2009 My parents were able to get their insurance company to reimburse them for most of their surgery at OCC, but they are retired government employees and have very good insurance. However it does indicate the tide is turning on insurance covering these things. No idea if insurance will cover your fills or how that will work out, but if you can go to your primary care physician and get a note from them stating you need fills you'll have a better chance. I used to have a health savings account where I had an amount of my choosing taken out of my paycheck before taxes, and then that money was used to reimburse my fills. Even though it was my money I still needed a note from my doctor that fills were medically necessary due to morbid obesity (he actually wrote this very large and underlined it to get the message across) before they were willing to send me a check. Alternatively you can do what I've done for the last year and date the son of a fill doctor, but this is not a viable option for all people. Link to comment Share on other sites More sharing options...
ksk Posted May 28, 2009 Author Report Share Posted May 28, 2009 Hummmm.... Date the son of a fill doctor... Not a bad idea. But my husband & children might have a problem with it! Okay - Thank you all for your replies. I'm going to wing-it and see what happens upon my return. Thank you again for taking the time to reply! Link to comment Share on other sites More sharing options...
tootsie_lou Posted May 28, 2009 Report Share Posted May 28, 2009 Alternatively you can do what I've done for the last year and date the son of a fill doctor, but this is not a viable option for all people. Girl, you are amazing in so many ways!! Link to comment Share on other sites More sharing options...
AngieB Posted May 28, 2009 Report Share Posted May 28, 2009 My parents were able to get their insurance company to reimburse them for most of their surgery at OCC, but they are retired government employees and have very good insurance. However it does indicate the tide is turning on insurance covering these things. No idea if insurance will cover your fills or how that will work out, but if you can go to your primary care physician and get a note from them stating you need fills you'll have a better chance. I used to have a health savings account where I had an amount of my choosing taken out of my paycheck before taxes, and then that money was used to reimburse my fills. Even though it was my money I still needed a note from my doctor that fills were medically necessary due to morbid obesity (he actually wrote this very large and underlined it to get the message across) before they were willing to send me a check. Alternatively you can do what I've done for the last year and date the son of a fill doctor, but this is not a viable option for all people. Clynn, my first question is, does he have a brother!? LOL J/K I am happily married, but got a kick out of your reply! Link to comment Share on other sites More sharing options...
shiney42 Posted May 29, 2009 Report Share Posted May 29, 2009 Ummmm Sorry but whats WLS? What insurance do you have? if you don't want it public pm me. Cause I'm curious as to how you plan on trying to do this... What Doc did you decide on? Or what place do you plan on going to? I have empire Blue Cross Blue Shield direct HMO. And wouldn't that kinda be or fall into fraudulent??????? If you fudge any paper work? Link to comment Share on other sites More sharing options...
shiney42 Posted May 29, 2009 Report Share Posted May 29, 2009 My parents were able to get their insurance company to reimburse them for most of their surgery at OCC, but they are retired government employees and have very good insurance. However it does indicate the tide is turning on insurance covering these things. No idea if insurance will cover your fills or how that will work out, but if you can go to your primary care physician and get a note from them stating you need fills you'll have a better chance. I used to have a health savings account where I had an amount of my choosing taken out of my paycheck before taxes, and then that money was used to reimburse my fills. Even though it was my money I still needed a note from my doctor that fills were medically necessary due to morbid obesity (he actually wrote this very large and underlined it to get the message across) before they were willing to send me a check. Alternatively you can do what I've done for the last year and date the son of a fill doctor, but this is not a viable option for all people. yeah but shes a Low BMI'er where you were Morbid, so that may make a difference Link to comment Share on other sites More sharing options...
Clynn Posted May 29, 2009 Report Share Posted May 29, 2009 Perhaps, but my point was that getting a doctor on your side goes a long way. The worst the insurance company can do say is no. Link to comment Share on other sites More sharing options...
ksk Posted May 30, 2009 Author Report Share Posted May 30, 2009 WLS = Weight Loss Surgery... 1st, let me just say that I would never ask or have a doctor "fudge" any paperwork. My point was that if the fill, which is a procedure, was done during an "in-office visit", then the doctor's office would/could/may code it as such. Along the same lines as when I bring my kids to their doctor - if he does a "strep test" in the office, I pay 2 co-pays: 1 for the visit and the 2nd for the "in-office procedure/test." So my hope is that if I see someone in their office where they do the fills there, it will be coded as such ("in office procedure/test") rather than having the fills done separately from the doctor's visit and coded separately/independent from the doctor visit. Sounds like a very convoluted question... In any case, I'm still looking into various doctors right now and haven't settled on anything yet - Link to comment Share on other sites More sharing options...
angelarias Posted May 30, 2009 Report Share Posted May 30, 2009 hi there: you'll find that many docs don't do fills unless they or their associates have banded. i budgeted for my bands and intial 3 fills to be done in mexico with ortiz. good luck on yr upcoming surgery! angel WLS = Weight Loss Surgery...1st, let me just say that I would never ask or have a doctor "fudge" any paperwork. My point was that if the fill, which is a procedure, was done during an "in-office visit", then the doctor's office would/could/may code it as such. Along the same lines as when I bring my kids to their doctor - if he does a "strep test" in the office, I pay 2 co-pays: 1 for the visit and the 2nd for the "in-office procedure/test." So my hope is that if I see someone in their office where they do the fills there, it will be coded as such ("in office procedure/test") rather than having the fills done separately from the doctor's visit and coded separately/independent from the doctor visit. Sounds like a very convoluted question... In any case, I'm still looking into various doctors right now and haven't settled on anything yet - Link to comment Share on other sites More sharing options...
shiney42 Posted May 30, 2009 Report Share Posted May 30, 2009 Perhaps, but my point was that getting a doctor on your side goes a long way. The worst the insurance company can do say is no. No I hear ya. I totally underastand, I just wasn't sure if you knew she was a low BMI'er, I am too and I was kinda thinking out loud, Knowing that Insurance would never pay! It's frustrating - I pay over 1300 a month for insurance, and you have to fight them on everything! Link to comment Share on other sites More sharing options...
shiney42 Posted May 30, 2009 Report Share Posted May 30, 2009 WLS = Weight Loss Surgery...1st, let me just say that I would never ask or have a doctor "fudge" any paperwork. My point was that if the fill, which is a procedure, was done during an "in-office visit", then the doctor's office would/could/may code it as such. Along the same lines as when I bring my kids to their doctor - if he does a "strep test" in the office, I pay 2 co-pays: 1 for the visit and the 2nd for the "in-office procedure/test." So my hope is that if I see someone in their office where they do the fills there, it will be coded as such ("in office procedure/test") rather than having the fills done separately from the doctor's visit and coded separately/independent from the doctor visit. Sounds like a very convoluted question... In any case, I'm still looking into various doctors right now and haven't settled on anything yet - DOH! WLS- ThanksI'm sorry I may have used the wrong word. I don't know about doctors codes and all that stuff, thats why I was asking, I also feel whatever you can get your insurance company to pay for (of cause with in the laws) THEN! Hell yeah! let them pay. And if you figured out a way maybe it would be helpful to me, Cause I really just never thought about going through insurance ever, Knowing I'm a low BMI I would be fighing for nothing... Anyways, I plan on going to TJ for my first fill & therefore knowing I still have time to figure out what I'm doing for the second fill. I also was thinking since I'm going back to OCC for the first fill once I know all is well, I wouldn't mind the second fill with no Flouro - Cause I do plan on going back to Mexico at lest agin in a few months for PS. I am going to take them up on a package deal. Oh I was forgetting - I also never thought about my out of network plan cause it's a differant Country, And just thought I wouldn't be covered! But I sure am going to look into it, Thanks Keep me updated Link to comment Share on other sites More sharing options...
pcbutts1 Posted July 3, 2009 Report Share Posted July 3, 2009 As far as I know,, once you go down the path of self pay,, or you have no insurance coverage,, you will have to pay for the fills yourself. When I tried to get my insurance to pay for the lap band, my employer had no WLS of any kind written into the policy. Which ment that any aftercare wouldn't be covered too. I don't know of anyone who had to self pay and then got their insurance to cover fills. If they did,, I'd like to know how they got it done. Well here's my story. My husband and I are both self pay and we had it done in Mexico in January. We have Kaiser. 1 month after his procedure his band had slipped. We went to kaiser and those doctors could not find anything wrong. He was in so much pain he had passed out a few times over this 8 day ordeal. All Kaiser would do was to give him a shot of diloted, morphine did not work, and send him home. This went on for 8 days until one doctor did his job and found another doctor who knew what the problem was. Until that day we had not known it had slipped. Now since Kaiser does not do lap bands the only option he gave us was to just remove it or remove it and give him a gastric Sleeve http://www.yourbariatricsurgeryguide.com/gastric-sleeve/ we went for the sleeve. The weight loss is about the same as he has now lost 70lbs. When talking to the nurses we found a doctor for my fills who is not a kaiser doctor but is a specialist and will take Kaiser patients by referal from kaiser. Kaiser gave me the referal for my first fill but for my second they wanted the doctor to send to them an explanation of what he will be doing so that they can justify paying for it. I am still waiting for that to be sent but it looks like I can get my fills paid for by Kaiser. Dr Billy will do fills for anyone. http://www.thebandmd.com/Default Link to comment Share on other sites More sharing options...
shiney42 Posted August 2, 2009 Report Share Posted August 2, 2009 Well here's my story. My husband and I are both self pay and we had it done in Mexico in January. We have Kaiser. 1 month after his procedure his band had slipped. We went to kaiser and those doctors could not find anything wrong. He was in so much pain he had passed out a few times over this 8 day ordeal. All Kaiser would do was to give him a shot of diloted, morphine did not work, and send him home. This went on for 8 days until one doctor did his job and found another doctor who knew what the problem was. Until that day we had not known it had slipped. Now since Kaiser does not do lap bands the only option he gave us was to just remove it or remove it and give him a gastric Sleeve http://www.yourbariatricsurgeryguide.com/gastric-sleeve/ we went for the sleeve. The weight loss is about the same as he has now lost 70lbs. When talking to the nurses we found a doctor for my fills who is not a kaiser doctor but is a specialist and will take Kaiser patients by referal from kaiser. Kaiser gave me the referal for my first fill but for my second they wanted the doctor to send to them an explanation of what he will be doing so that they can justify paying for it. I am still waiting for that to be sent but it looks like I can get my fills paid for by Kaiser. Dr Billy will do fills for anyone. http://www.thebandmd.com/Default I forgot, But KSK did you get your fill yet? If so how did it go? and did you ever figure about submitting the forums? :-? Link to comment Share on other sites More sharing options...
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