[MJ Fan]

I had to have my primary care physician give me clearance and I could only get clearance from my pcp if I had a thyroid check that all turned out fine.

I had to do the psychiatrist evaluation everything turned out fine and the cardiologist evaluation which turned out fine. I only had to get the cardiologist evaluation sine I have a heart disease. I also had to see a nutritionist. Only reason I think I did not have to do a sleep study test is I had one done last and I only mild sleep apnea and I did not have to wear a mask at night. It took Medicaid two weeks to approve me. Then I had my surgery scheduled and got a call back saying the surgeon did not take GA Better Health Care which is what Medicaid is through.

My husband called the surgeon's office and said that they should have told us that to begin since on my Medicaid card it says GA Better Health Care. But he was pushy with the surgeon's office. Then a week or two later we got an unexpected call from my surgeon's office saying it is approved. I told my husband to ask is this really for real he asked the insurance person at the surgeon's office and she said it is really for real this time. So I had my surgery March 24 this year. I still don't see why my surgeon didn't take GA Better Health care even though I had Medicaid insurance and he takes Medicaid. My husband and I both think the only reason the surgeon's office worked it out the insurance is because he was very pushy. When we were told the surgeon did not take GA Better Health Care we were both upset not just because I was not getting the surgery but because we spent nearly $1,000 dollars on the evaluations. At least it worked out and I got the gastric bypass surgery.

[MsVickie]

Honey that 1,000 worth of bills needs to be sent to Medicaid. They should pick that up also. No reason they should not. If they approved you for surgery then that means they approved the surgeon you went to . This is insane you know. Sigh.... when i first started mine I wanted deep in my heart to be a insurance advocate for people.

People think its the Doctors fault for charging so much and its not true. Its the insurance companies. I have dealt with them on a professional level so long I know how that system works. Its not like years ago when we was children. Trust me.

[pretty woman]

It just goes to show it pays to be persistent. I think we all have to be assertive-not nasty aggressive, but assertive and we need to be sure to follow through on everything.
I kept a notebook. At each appt I wrote the doctor's name and almost everything he/she said. Whenever I spoke to anyone regarding the surgery, I wrote it down, when and who I talked to, and summarized the conversation. It was a help.. you forget things, it is a stressful time, having it in writing helped me.
I think you should put "in" for the $1,000.00 too. All those services were required, they should pay.

[MJ Fan]

The reason I had to pay that is the insurance refused to pay for the evaluations. I had my primary doctor send a referral to the nutritionist and it was declined by Medicaid. I just look it at this way $1,000 is not much considering the surgery was around $20,000. My DH called several psychiatrists to see if they accepted Medicaid and none of them did. I only had to pay for 2 out of 4 evaluations.

[hippiechick72]

I am glad everything worked out for you. I worked in the medical field for several years. Part of my job was verifying insurance for patients. Dealing with Indiana Medicaid(which I have now) was frustrating. You could call them 2 separate times and get 2 different answers. Sometimes I had to explain their handbook to them, to prove that they did cover a procedure for a patient!! I have Anthem through medicaid and it is better than before. Momma always said, "what doesn't kill us will make us stronger." LOL, a lil crazier too. Great idea Pretty Woman....I will start doing this asap

[KatV]

I'm so glad that you and your DH were persistent and that you were able to have the surgery!! I think it will swerve you well on your WLS journey. Congratulations and continued success.

[kdsmiles]

Good for you!! Congrats Sweety... it does pay to be persistent and Thank you for sharing this story to help others see this as well! I have Blue Cross and they were great!

[MJ Fan]

Originally Posted by KatV

I'm so glad that you and your DH were persistent and that you were able to have the surgery!! I think it will swerve you well on your WLS journey. Congratulations and continued success.

Thank you. All though it was my husband who was persistent with the surgeon's office not me. He was really mad at them. I loved it when he said "my wife's insurance card said on the front says GA Better Health Care on it why did no one tell us that Dr. Williams did not accept GA Better Health Care" he was mad too. While we waited to find out if I was approved or not he must of called the surgeon's office over a dozen times. I loved it when my husband said to me they must be so sick of him by now. I found that funny. I couldn't help but laugh when he said that.

[darmstead38]

I have gone though everything, including what I consider a lot pre op sessions, that took a year. I have seen the Dr, and now we are waiting the approve of medicare. He said it could take up to 2-3 months....
My summer plans are on hold since I don't know when I will have the surgury.. it bothers me. I have a good mind to call the dr office the first week of june, just to say "hi, has is there any good news from medicare?"
I am grateful to now since so much time has time, I have gone over and over, ad nausea about if I really should have the surgery. Now I know for sure.

[bonincontrus]

MJ Fan I had mine done through Maryland Medicaid sponsored through Johns Hopkins Priority Partners. In another thread I had listed down the expenses they medicaid paid and what I paid.

I know where Vickie is coming from but since the medicaid system is run through FEDERAL funds the regulations are the same in every state. Each state may have something set up in addition to what the federal regulations are but they have to follow federal first. They will not pay for evals. The only way around that is if you went to that Dr. for a previous issue already referred by your PCP. Like if you had the heart condition you ALREADY see that particular cardiologist for on a regular (I think it has to be at least every 90 days) basis. And they will not pay the program fee that most places have or the psych eval usually. That is the same for regular insurances too, some things they pay for, some they don't If I remember right, my out of pocket was around $1700 so far.

What I needed:
I was in the first 5 people at my center with medical assistance to be accepted there so I was a bit of a guinea pig.
-history of documented previous weight loss efforts. Like I had to even provide the contract and/or the receipts from the Jenny Craig program from 2 years ago type stuff
-weight loss effort with my pcp and pcp referral
-bmi over 35 or 25-30 with co-morbidness (I had co's and that is what approved me though my bmi was lower)
-6 months of food journals reviewed by wls surgeon seen at LEAST once per month. They will deny you if you are a day short or missing even one day of food journal (edited to add) if I missed even one appointment in the month and didn't make it up within the same month I would have to start the whole six months over again
-psych evaluation and follow ups
-attend 6 month nutrition counseling and wls counseling
-show ability to handle financially and emotionally life after surgery
-sign contract about not drinking alcohol for at least a year after surgery
-sign contract for exercise

Between medical assistance and my own personal wls Dr.'s opinion about why people relapse and fail a couple years out they put these rules into place so people can have long term success.