good news

[Guest guest]

HOORAY!!! A big hurdle has just been crossed for me!!!! My insurance company

called a little while ago and said that I have been approved to have this

surgery because of medical necessity!! Yeah!!!! It's a miracle!!!!!!!!!!

I am very excited, but I am trying to remain somewhat calm because we still

have to find out how much of it they are going to cover. My book says they

will only cover 60% of surgeries that are out of network, and we don't know yet

if we can get them to cover this at in network percentages. The only WLS I

know of that is done in my network is open RNY, so the comparatively low MGB

costs should look good to the insurance company.

We have called the insurance representative at my husband's workplace, and she

says that the per person maximum that I should have to pay per year out of

pocket is $1,250 of which $250 is my deductible, which I have already met this

year. So that should mean that no matter what rate they cover the surgery at,

I should still only have to pay $1000. Does that seem correct to you insurance

experts out there? The rep did say that they make you pay any costs that they

feel are unreasonable out of your pocket, over and above the $1000. For

example, if the hospital charges $10 for an aspirin, and the insurance company

only allows $5 for an aspirin, then I would have to pay the other $5 in

addition to the $1000.

So all this sounds all right because I can pay as much as $1000 up front, and

could pay the rest later, but what I am worried about are the following things:

1) Whether the hospital and/or Dr. R will require that I pay upfront the

percentage that the insurance company says they won't cover. Does anyone know

if they will require any upfront payment even if I can show them that I have a

personal yearly maximum of $1000? Because I can't afford to pay 40% of this

surgery upfront, even if I am going to be reimbursed later, because I just

don't have access to that kind of money all at once.

2) I also worry (hopefully unreasonably) that they will change their minds and

not cover me (or decide not to cover the MGB) because I have to wait for a

letter to come from some other office in another state saying that I am

approved, according to the insurance caseworker who called me.

3) I will be devastated if, after all of this, something happens and I can't

have the surgery.

The insurance company said they will call Dr. R's office this afternoon and set

a surgery date for me, so I called Debbie and told her that they will be

calling, and she said I can have surgery on August 2nd. I am so glad!!!

If anyone can give me any advice or reassurance about the insurance questions

above, I would really appreciate it. If all goes well, I will be at clinic on

August 1st, and have surgery on August 2nd!!!!! Anyone else on those dates?

Sara

BMI 43 (but not for long!)