insurance

[Guest guest]

This pretty normal about family and friends. I like to think of it as they are just uneducated. They is a great site to come and ask questions or get support. I can remember feeling like I had "found my people" when I found everyone on this site. Someone was always there to answer my questions, and I felt so safe and secure asking what I asked here. There are NO bad questions to ask--so just ask away.

Just keep coming back here. You will be able to help someone too one of these days.

Hugs,

Suzann

In a message dated 11/18/2009 2:20:44 P.M. Pacific Standard Time, shrlols@... writes:

Thanks for the info, my mind is worrying about everything. My surgery date is 12/12 I have found I can't talk

to very many friends or family , who are totally uninformed, talk about negative feedback. yikees.

Re: Insurance

You have a legal right to have surgery anywhere you want. Ins co's don't really care where you had it as long as they don't have to pay for it. ;o) There really isn't any aftercare for a sleeve. The sutures are self dissolving. You just get your annual labs from your PCP like you would even if you didn't have WLS. Dr. A does like for us to get an upper GI and labs at three months. I didn't.

On Wed, Nov 18, 2009 at 11:07 AM, Kim Rehn <kitr319 > wrote:

What about after care? If I need to go to the doctor for something (I don't know what) and they find out I had wls in Mexico, will insurance typically cover things once it's done? I'm getting the sleeve December 19th! Yeah!!!!

[Guest guest]

Sometimes they do! I know two people (married couple) that had US insurance pay

for their lap bands. They had to pay up front and then ins reimbursed them.

But I think the question you are responding to is something a little different.

I think she wants to know if she will have problems with her ins after surgery,

not that they would pay for it in MX.

>

> Health Care Company's here in the US will never pay for WLS outside of the

> US. WE have all paid for our own surgery.

>

> Suzanne

>

>

> In a message dated 11/18/2009 7:28:27 A.M. Pacific Standard Time,

> shrlols@... writes:

>

>

>

>

> Has anyone had any problems with their health insurance covering them

> after sleeve surgery

> done in Mexacali?

> I have United Healthcare, they wouldn't cover me for WLS in US.

> Also can anyone tell me if you can have coffee after having the sleeve

> surgery?

> Thanks....

> Shirley

>

[Guest guest]

What about after care? If I need to go to the doctor for something (I don't know what) and they find out I had wls in Mexico, will insurance typically cover things once it's done? I'm getting the sleeve December 19th! Yeah!!!!

From: SuzanneSH@... <SuzanneSH@...>Subject: Re: Insurance Date: Wednesday, November 18, 2009, 5:33 PM

Health Care Company's here in the US will never pay for WLS outside of the US. WE have all paid for our own surgery.

Suzanne

In a message dated 11/18/2009 7:28:27 A.M. Pacific Standard Time, shrlolsaol (DOT) com writes:

Has anyone had any problems with their health insurance covering them after sleeve surgery

done in Mexacali?

I have United Healthcare, they wouldn't cover me for WLS in US.

Also can anyone tell me if you can have coffee after having the sleeve surgery?

Thanks....

Shirley

[Guest guest]

You have a legal right to have surgery anywhere you want.  Ins co's don't really care where you had it as long as they don't have to pay for it. ;o)  There really isn't any aftercare for a sleeve.  The sutures are self dissolving.  You just get your annual labs from your PCP like you would even if you didn't have WLS. 

Dr. A does like for us to get an upper GI and labs at three months.  I didn't.On Wed, Nov 18, 2009 at 11:07 AM, Kim Rehn <kitr319@...> wrote:

 

What about after care?  If I need to go to the doctor for something (I don't know what) and they find out I had wls in Mexico, will insurance typically cover things once it's done?  I'm getting the sleeve December 19th!  Yeah!!!!

[Guest guest]

I know my insurance does not pay for WLS, my question is, has anyone had trouble with their

insurance coverage for any aftercare for anything if done outside the US.

Insurance

Has anyone had any problems with their health insurance covering them after sleeve surgery

done in Mexacali?

I have United Healthcare, they wouldn't cover me for WLS in US.

Also can anyone tell me if you can have coffee after having the sleeve surgery?

Thanks....

Shirley

[Guest guest]

If your ins will cover a procedure they cover it period.  It does not matter where you have something done.  Either a procedure is covered or it is not.On Wed, Nov 18, 2009 at 11:45 AM, <shrlols@...> wrote:

 

I know my insurance does not pay for WLS, my question is, has anyone had trouble with their

insurance coverage for any aftercare for anything if done outside the US.

[Guest guest]

Thanks for the info, my mind is worrying about everything. My surgery date is 12/12 I have found I can't talk

to very many friends or family , who are totally uninformed, talk about negative feedback. yikees.

Re: Insurance

You have a legal right to have surgery anywhere you want. Ins co's don't really care where you had it as long as they don't have to pay for it. ;o) There really isn't any aftercare for a sleeve. The sutures are self dissolving. You just get your annual labs from your PCP like you would even if you didn't have WLS.

Dr. A does like for us to get an upper GI and labs at three months. I didn't.

On Wed, Nov 18, 2009 at 11:07 AM, Kim Rehn <kitr319 > wrote:

What about after care? If I need to go to the doctor for something (I don't know what) and they find out I had wls in Mexico, will insurance typically cover things once it's done? I'm getting the sleeve December 19th! Yeah!!!!

[Guest guest]

No Coffee for 3 months post op according to Gaby. I was so sad.

From: shrlols@... <shrlols@...>Subject: Insurance Date: Wednesday, November 18, 2009, 1:01 AM

Has anyone had any problems with their health insurance covering them after sleeve surgery

done in Mexacali?

I have United Healthcare, they wouldn't cover me for WLS in US.

Also can anyone tell me if you can have coffee after having the sleeve surgery?

Thanks....

Shirley

[Guest guest]

I didn't tell anyone about my surgery and hid out at my place in Mexico for a month. I finally told my daughter who thought I had cancer because I was losing weight so rapidly. She thought it was wonderful but, who knows why, cautioned me not to tell anyone else. She says it isn't any of their business. Family asks my daughter how I lost so much weight and she says I have been dieting and exercising, which is partially true. Not everyone is supportive of our surgeries so if you sense that might be the case, keep it to yourself. You don't need negative feedback. Just be smug in the knowlege that next year you will be a whole lot smaller and you can say it's due to dieting and exercising, too.

From: "shrlols@..." <shrlols@...> Sent: Wed, November 18, 2009 1:41:20 PMSubject: Re: Insurance

Thanks for the info, my mind is worrying about everything. My surgery date is 12/12 I have found I can't talk

to very many friends or family , who are totally uninformed, talk about negative feedback. yikees.

Re: Insurance

You have a legal right to have surgery anywhere you want. Ins co's don't really care where you had it as long as they don't have to pay for it. ;o) There really isn't any aftercare for a sleeve. The sutures are self dissolving. You just get your annual labs from your PCP like you would even if you didn't have WLS. Dr. A does like for us to get an upper GI and labs at three months. I didn't.

On Wed, Nov 18, 2009 at 11:07 AM, Kim Rehn <kitr319 (DOT) com> wrote:

What about after care? If I need to go to the doctor for something (I don't know what) and they find out I had wls in Mexico, will insurance typically cover things once it's done? I'm getting the sleeve December 19th! Yeah!!!!

[Guest guest]

Hmmmm you mean I can have coffee?!!! Oh my! I have been craving it just from the smell of others! Then again...I wasn't that much of a coffee drinker and I think I just wanted what I couldn't have!

From: brianne williams <jbriannewilliams@...> Sent: Wed, November 18, 2009 7:03:23 PMSubject: Re: Insurance

No Coffee for 3 months post op according to Gaby. I was so sad.

From: shrlolsaol (DOT) com <shrlolsaol (DOT) com>Subject: Insurance @groups. comDate: Wednesday, November 18, 2009, 1:01 AM

Has anyone had any problems with their health insurance covering them after sleeve surgery

done in Mexacali?

I have United Healthcare, they wouldn't cover me for WLS in US.

Also can anyone tell me if you can have coffee after having the sleeve surgery?

Thanks....

Shirley

Looking for the perfect gift? Give the gift of Flickr!

[Guest guest]

My dr in the US said I may need an endoscopy ($1200) and after that probably need to have my band repositioned. They checked and my insurance wouldn't cover any of it. They said they needed $600 from me before they would perform the endoscopy. So far my insurance has denied paying for any fills but they covered my first fluro because it was performed because of pain. Cyrena From: "shrlols@..." <shrlols@...> Sent: Wed, November 18, 2009 12:45:55 PMSubject: Re: Insurance

I know my insurance does not pay for WLS, my question is, has anyone had trouble with their

insurance coverage for any aftercare for anything if done outside the US.

[Guest guest]

Wouldn't it be cheaper for you to go back to the best doc in the world?On Thu, Nov 19, 2009 at 5:57 PM, Cyrena Weeks <cyrenaweeks@...> wrote:

 

My dr in the US said I may need an endoscopy ($1200) and after that probably need to have my band repositioned.  They checked and my insurance wouldn't cover any of it. They said they needed $600 from me before they would perform the endoscopy.  So far my insurance has denied paying for any fills but they covered my first fluro because it was performed because of pain.

 Cyrena

[Guest guest]

$1200 isn't bad. I had an endoscopy is June as a pre-op test before surgery, and

they billed my insurance company $9,000!

>

> My dr in the US said I may need an endoscopy ($1200) and after that probably

need to have my band repositioned. They checked and my insurance wouldn't cover

any of it. They said they needed $600 from me before they would perform the

endoscopy. So far my insurance has denied paying for any fills but they covered

my first fluro because it was performed because of pain.

>

> Cyrena

>

>

>

>

>

> ________________________________

> From: " shrlols@... " <shrlols@...>

>

> Sent: Wed, November 18, 2009 12:45:55 PM

> Subject: Re: Insurance

>

>

> I know my insurance does not pay for WLS, my question is, has anyone had

trouble with their

> insurance coverage for any aftercare for anything if done outside the US.

>

[Guest guest]

What they bill and what the contracted amount will be paid are two verrrry different things.On Fri, Nov 20, 2009 at 8:53 AM, extraordinarybags <april.white@...> wrote:

 

$1200 isn't bad. I had an endoscopy is June as a pre-op test before surgery, and they billed my insurance company $9,000!

[Guest guest]

Oh yeah and I did!!! I called and talked to Rena, she told me the tests they were ordering we unnecessary and at this point I didn't have a slip, Dr. Compos ordered an all liquid diet and I'm doing that right now. Grand total cost for that----- FREE!!!! They are the BEST!!! Cyrena From: Bipley <Bipley@...> Sent: Fri, November 20, 2009 5:47:13 AMSubject: Re: Insurance

Wouldn't it be cheaper for you to go back to the best doc in the world?On Thu, Nov 19, 2009 at 5:57 PM, Cyrena Weeks <cyrenaweeks> wrote:

My dr in the US said I may need an endoscopy ($1200) and after that probably need to have my band repositioned. They checked and my insurance wouldn't cover any of it. They said they needed $600 from me before they would perform the endoscopy. So far my insurance has denied paying for any fills but they covered my first fluro because it was performed because of pain.

Cyrena

[Guest guest]

Hey...

Well... I started drinking decaf coffee right away on the full liquid stage

after surgery... but everyone is different... as soon as I went to the soft food

stage I have been able to drink regular coffee... both with cream and splenda or

equal. Everyone is different, and some can tolerate it and some can't... so use

caution and drink decaf at first. Nina told me... if you can tolerate decaf

coffee, you should be able to tolerate regular coffee as well... good luck!!!

>

>

> From: shrlols@... <shrlols@...>

> Subject: Insurance

>

> Date: Wednesday, November 18, 2009, 1:01 AM

>

>

>  

>

>

>

>

> Has anyone had any problems with their health insurance covering them after

sleeve surgery

> done in Mexacali? 

> I have United Healthcare, they wouldn't cover me for WLS in US.

> Also can anyone tell me if you can have coffee after having the sleeve

surgery?

> Thanks....

> Shirley

>

[Guest guest]

Just a thought, maybe the coffee is causing you problems. I started having stomach pain from acid and when I have coffee it is bad, bad. Try to back off the coffee all together and see what happens with your reflux and stomach pain.

Cyrena

DOB: 1/19/07

240/136/150

start/now/goal

From: suziemellis <suziemellis@...> Sent: Mon, November 23, 2009 3:33:46 AMSubject: Re: Insurance

Hey...Well... I started drinking decaf coffee right away on the full liquid stage after surgery... but everyone is different... as soon as I went to the soft food stage I have been able to drink regular coffee... both with cream and splenda or equal. Everyone is different, and some can tolerate it and some can't... so use caution and drink decaf at first. Nina told me... if you can tolerate decaf coffee, you should be able to tolerate regular coffee as well... good luck!!!> > > From: shrlols@...

<shrlols@... >> Subject: Insurance> @groups. com> Date: Wednesday, November 18, 2009, 1:01 AM> > >  > > > > > Has anyone had any problems with their health insurance covering them after sleeve surgery> done in Mexacali? > I have United Healthcare, they wouldn't cover me for WLS in US.> Also can anyone tell me if you can have coffee after having the sleeve surgery?> Thanks....> Shirley>

[Guest guest]

Hi,

The feelings of anxiety and being overwhelmed is quite normal no matter how much you want the surgery and can't wait to get it. The people on this board were always there for me when I needed someone to prop me up. I made the mistake of sharing with some of my family what I was going to do. Some were great about it and some were pretty awful about what I was doing. I think because they had a lot of information that was wrong and believe it or not they got it from their very own medical doctor. Not all doctors really know that much about sleeve surgery--sometimes they need to be educated too. They kept getting it mixed up with bypass surgery and were tell my two kids all the wrong information. It took my son and daughter quite awhile to accept what I was going to do. To this day (because my son is overweight) they still won't say Gee Mom we are glad you are so healthy or gee Mom we have never seen you look this good. They just don't talk about it. It is like if we don't talk about it, then we won't have to deal with the issues of being overweight. At least my son is overweight. My daughter works very hard at trying to keep it off, and I have noticed that she has gain some weight over this last year. They both have a lot of stress in their lives and that isn't good.

You will go through all kinds of feelings an emotions. It is quite normal. I think what you are doing is wonderful. And reading the postings really does get you through a lot of the anxiety. Try going in and looking at the pictures of people before, after and along their weight loss journey. That really use to motive me. I know for me I tried to make sure I posted a picture every month so I could see my weight loss also. Keep doing what you are doing and come back here and check in with us as often as you want.

Take care,

Suzanne

245 (highest weight)

225 132 125

Start Now Goal

Sleeved Oct 2008

In a message dated 11/23/2009 1:42:26 P.M. Pacific Standard Time, shrlols@... writes:

Thanks for the info, of all the things i'm trying to change, cutting back on coffee has been the hardest

so far. Not a big deal i know, just one of my addictions. My sleeve surgery is Dec 12, and anxiety overwhelms

me at times, to much time to think. I don't want to exchange one set of health issues only to have new ones

to deal with. The posts on this board keep me going, I've even went back and re-read old enteries.

Insurance> > Date: Wednesday, November 18, 2009, 1:01 AM> > >  > > > > > Has anyone had any problems with their health insurance covering them after sleeve surgery> done in Mexacali? > I have United Healthcare, they wouldn't cover me for WLS in US.> Also can anyone tell me if you can have coffee after having the sleeve surgery?> Thanks....> Shirley>

[Guest guest]

Thanks for the info, of all the things i'm trying to change, cutting back on coffee has been the hardest

so far. Not a big deal i know, just one of my addictions. My sleeve surgery is Dec 12, and anxiety overwhelms

me at times, to much time to think. I don't want to exchange one set of health issues only to have new ones

to deal with. The posts on this board keep me going, I've even went back and re-read old enteries.

Insurance

>

> Date: Wednesday, November 18, 2009, 1:01 AM

>

>

> Â

>

>

>

>

> Has anyone had any problems with their health insurance covering them after sleeve surgery

> done in Mexacali?Â

> I have United Healthcare, they wouldn't cover me for WLS in US.

> Also can anyone tell me if you can have coffee after having the sleeve surgery?

> Thanks....

> Shirley

>

[Guest guest]

As you can see I am attempting to get the link to the ICD- 9 codes via . I

will post as soon as she responds to me.

The insurance information is entered into the computer along with the order. The

insurance will apply and calculate the coverage. patient pays any co-pay which

is deducted from the amount the insurance will cover and the remainder is paid

by the insurance to the pharmacy. many times the insurance wlll not pay for all

that the pharmacy has billed. In this case the pharmacy is 'out' that much

reimbursement.

Bill $50

Pt pays co-pay of $10

Insurance pays total of $38

Pharmacy is reimbursed $48 of the $50

Pharmacy is out $2

Does this help?

Jeanetta Mastron CPhT BS

Founder/Owner

>

> doea anyone know all the insurance codes for pharmacy?

>  

>  

> how does third party work in a pharmacy?

>  

>  

> thanks

>

>

>

>

>

[Guest guest]

Third party payers negotiate a payment to the pharmacy on behalf of their

clients at a rate less than the cash price of a prescription.

As an example, let's say ABC Pharmacy charges a cash price of $165.00 for Aczone

gel 60 gms. Doe has an Aetna insurance policy paid through his employer.

Aetna is the third party payer. Aetna negotiates a price based on the AWP of

Aczone with ABC Pharmacy to pay ABC Pharmacy $100.00 for Aczone gel gms with a

$3.00 dispensing fee. As part of Doe's policy, Aczone is a non-formulary

drug with a co-pay of $50.00. ABC Pharmacy dispenses the prescription recieving

$103.00 from the Aetna and $50.00 from Doe.

Any questions?

>

> doea anyone know all the insurance codes for pharmacy?

>  

>  

> how does third party work in a pharmacy?

>  

>  

> thanks

>

>

>

>

>

[Guest guest]

Thanks for posting !

 

Jeanetta Mastron CPhT BS

F/O

 

From: mariacpht <cphtgenius@...>

Subject: Re: insurance

Date: Thursday, December 17, 2009, 3:58 PM

Third party payers negotiate a payment to the pharmacy on behalf of their

clients at a rate less than the cash price of a prescription. 

As an example, let's say ABC Pharmacy charges a cash price of $165.00 for Aczone

gel 60 gms.  Doe has an Aetna insurance policy paid through his employer. 

Aetna is the third party payer.  Aetna negotiates a price based on the AWP of

Aczone with ABC Pharmacy to pay ABC Pharmacy $100.00 for Aczone gel gms with a

$3.00 dispensing fee.  As part of Doe's policy, Aczone is a non-formulary

drug with a co-pay of $50.00.  ABC Pharmacy dispenses the prescription recieving

$103.00 from the Aetna and $50.00 from Doe.

Any questions?

>

> doea anyone know all the insurance codes for pharmacy?

>  

>  

> how does third party work in a pharmacy?

>  

>  

> thanks

>

>

>       

>

>

[Guest guest]

Hi ,

 

Congratulations on your new knees.  You were brave to have two done at the same

time.  That is really great to have that behind you.

 

How disappointing for you to find out your PT was not fully covered. Prior to

starting PT I called my insurance company to ask about coverage.  What they

told me was both surprising and pleasing.  They said I would have a total of

120 visits in house at the rehab center, another 100 days in home, and 40 at a

PT center.  I should be ok...but as we all know...insurance companies are full

of surprises.  Lets hope not in this case.

 

Thank you for bringing that to my attention...I will keep my eyes open for any

surprises.

 

Gayle

 

Re: Gayle

Hi Gayle,

I have been a lurker in the group for a while. I had bilateral TKR done in

July 2009, so just had my one year anniversary. :-) A year post-op and I

feel so much better than I did before surgery.

Prior to surgery, I had severe contractures in both knees. I had horrible

pain. I can look back with some humor now, but would not have described it

this way then (the pain colored everything), but I " wobbled when I walked "

because of the contractures.

It is good that you are doing some PT " pre-hab " prior to surgery. It will

help. Let me forwarn you though! I had pre-hab too....22 visits in the

Feb-April timeframe. I made the decision to get surgery May 5. (My

Independence Day so to speak.) My OS told me to stop PT immediately at that

time as I'd need every single session after surgery for rehab. My insurance

covers 60 sessions per year. Between what I did before surgery, and the

sessions after surgery, I used up my 60 sessions by the end of October. I

had two months of 3x sessions that my insurance wouldn't pay for, and I was

stuck with a $6855.99 PT bill! I did appeal the decision and my insurance

picked up over half that amount, but I am now making payments on the

remaining portion. I hate the fact I have to pay it, that money could be a

car payment, go to savings, whatever. BUT....I needed the PT, I am better

off because of it and I am worth it!

A bit of advice: check with your insurance company to see if you can get

extended sessions (beyond the 40 limit) preauthorized. Keep track during

the year how many sessions you have remaining as you use them. If you can

get sessions approved beyond the 40, get the pre-authorization started in

ample time. You don't know what your PT needs will be till you're going

through it. (I never thought I'd be needing as much PT as I did.)

LTKR 7/16/09, RTKR 7/20/09

Dr. Teeny, Tacoma, WA

------------------------------------

[Guest guest]

Tracey, with the bilateral knee replacement when you are doing the

PT do they charge you for two parts of the body or just as though

it is just one knee? Seems like the insurance company should

give you twice as many visits with two limbs involved......Wishful

thinking? BARB

Re: Gayle

Hi Gayle,

I have been a lurker in the group for a while. I had bilateral TKR done in

July 2009, so just had my one year anniversary. :-) A year post-op and I

feel so much better than I did before surgery.

Prior to surgery, I had severe contractures in both knees. I had horrible

pain. I can look back with some humor now, but would not have described it

this way then (the pain colored everything), but I " wobbled when I walked "

because of the contractures.

It is good that you are doing some PT " pre-hab " prior to surgery. It will

help. Let me forwarn you though! I had pre-hab too....22 visits in the

Feb-April timeframe. I made the decision to get surgery May 5. (My

Independence Day so to speak.) My OS told me to stop PT immediately at that

time as I'd need every single session after surgery for rehab. My insurance

covers 60 sessions per year. Between what I did before surgery, and the

sessions after surgery, I used up my 60 sessions by the end of October. I

had two months of 3x sessions that my insurance wouldn't pay for, and I was

stuck with a $6855.99 PT bill! I did appeal the decision and my insurance

picked up over half that amount, but I am now making payments on the

remaining portion. I hate the fact I have to pay it, that money could be a

car payment, go to savings, whatever. BUT....I needed the PT, I am better

off because of it and I am worth it!

A bit of advice: check with your insurance company to see if you can get

extended sessions (beyond the 40 limit) preauthorized. Keep track during

the year how many sessions you have remaining as you use them. If you can

get sessions approved beyond the 40, get the pre-authorization started in

ample time. You don't know what your PT needs will be till you're going

through it. (I never thought I'd be needing as much PT as I did.)

LTKR 7/16/09, RTKR 7/20/09

Dr. Teeny, Tacoma, WA

------------------------------------

[Guest guest]

Hi Bee,

I was thinking that maybe I should get some type of insurance for myself

and my daughter. I know I'm healing at the moment and I don't think I'll ever go

back to Drs. But I still think it would be wise to carry insurance.Especially

now that I have a tooth ache I wish I would've had dental insurance. So I

decided I need to get it for emergency God forbid but sometimes they just happen

and I want to be prepared. Do you have any suggestion on some insurance

companies that I can look into. That would be very helpful.Thank you Bee.

Irma P