Insurance Update

Dr. Albear’s office called today after receiving a reply from BCBS regarding their submission for pre-determination of my brachioplasty and mastopexy. The insurance coordinator said that BCBS’s response was “we don’t do predetermination on those procedure codes.”

So. That means you must have the procedures first and then submit the claims. And undoubtedly get a denial. And then appeal. And then get denied again. And then ask for a review. And probably get denied again.

Dr. Albear’s office knows this game, so the coordinator said “we would need you to self-pay, then we would submit to insurance and reimburse you if the claim is paid.”

And I think to myself, what motivation do they have to help me fight for an appeal if they’ve already been paid in full? Especially if getting insurance payment means getting less money since we all know the negotiated in-network costs to BCBS would be far less than I’d pay as a self-pay client.

On top of these realities, I have to be totally honest: I do not have rashes. I do not have fungus or smells or any of the other creepy stuff I’ve heard people complain about. I just have loose skin. In my personal opinion, this is reconstructive. But I don’t have a medical case for that.

So I’m officially self-pay. This is no surprise.

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First Plastics Consult

So yesterday’s plastic surgery consult was with Dr. Albear, who comes highly recommended from the OH board for my state. He’s also the only local plastic surgeon that will even try for insurance coverage for these procedures. On top of that, he’s really the only surgeon I’m looking at who has a specific case history of massive weight loss patients: everybody else is your basic breast implant, mommy makeover type of surgeon.

So those are the plusses for Dr. Albear, and the reasons he had been pretty high on my list of possibilities to start out with. The one down side is that he operates in Tampa, which is a good 2.5 hours from where I live. That’s a pain for the drive home the day of (or day after) surgery, and it’s a bit of hassle getting to his Lakeland office (1.5 hours) for follow up appointments. But I’d travel as far as necessary to get the right person to do my procedures!

So I walked in knowing (1) I need a brachioplasty, and (2) I need my boobs fixed, whatever that entails.

Lee came with me for moral support, and because he’s 100% behind these surgeries. He knows I’m miserable with my arms, and I know he’s miserable with my boobs! We assumed I would need implants to get some kind of reasonable size, but more on that later.

When Dr. Albear walked in, he began with a schpiel on what he requires out of massive weight loss patients:

  1. a prealbumin level in the range of 18-40. Prealbumin measures hepatic protein levels, which is basically protein in the blood, which is essential for healthy healing. If my first blood test is low, he would recommend protein supplements. (hahaha! I’m the queen of protein supplements!) I haven’t had prealbumin tested on any of my previous labs, but my protein total, albumin, and albumin/globulin ratio were all in normal ranges, so I don’t expect any problems with this.
  2. a hemoglobin level greater that 11. Since many (most?) of us weight loss patients develop anemia, he wants to make sure I’m not anemic before surgery. On my most recent labs, hemoglobin was 13.8 so again, no problems expected with this.
  3. a reasonable BMI. He explained that better results and better sculpting come with a lower BMI. He doesn’t like to do procedures on a BMI of 3o or more (I make the cut! I’m 29.9!)
  4. since many massive weight loss patients need multiple procedures, his rule is no more than 6 hours in surgery. He said that he can begin to get tired after operating for 6 hours, so his rule is no more than 6 hours in the operating room at a time.

Now. Everything is cool until the 6-hour rule. I understand the philosophy behind it and I respect the reasoning, but this would mean two separate procedures for my arms and breasts. Which means two recoveries. And it also means the expense of two facility fees.

Then again, safety first!

Dr. Albear explained that for massive weight loss patients, he usually performs surgery in the following stages: midsection first, since most people are most troubled by their belly. Then arms, maybe breasts, and only then on to thighs. He explained how much he hates thigh surgeries–healing is poor, wounds reopen, and this corresponds with every horrible thing I’ve heard about thigh lifts on the OH boards. So he won’t do thigh lifts until the very end when he knows exactly how a patient heals, and he never performs thigh lifts in conjunction with any other procedure. So that’s good to know for future reference.

Anyhow, I explained that I’m not interested in working on my midsection now since Lee & I are probably going to have kids within the next 4-5 years. I’d rather wait until all that is done before addressing that area.

Lee left the room when it was time for Dr. Albear to examine me. He didn’t want to have to watch the doctor “caress my breasts.” I tried to explain that there wouldn’t be any caressing going on, but Lee didn’t believe me!

So see left, I put on the paper gown, and Dr. Albear and his assistant came back in. Let me just say this: if you realize your skin is jacked up at home, just wait until you see in the lighting of a doctor’s office! Just wait until you see it contrasted to all the beautiful “after” pictures of procedures all over the place. Man, I looked a mess. Totally embarrassing. Getting the pictures taken was such a reality check!

So anyway, Dr. Albear examined me, and no surprises there. We talked about doing my arms first, and then a breast lift 6 weeks later as long as I’m healing properly. That he can’t guarantee a cup size, but that I’d probably wind up a C cup with my own tissue during a breast lift (I’m wearing a D now). Etc. etc. Dr. Albear explained that they would submit the procedures to insurance, they’d be prepared to walk me through an appeal, and then we’ll see what happens. Sounds good to me! I don’t expect insurance coverage, but if they have a way to make it happen, I’m all for it.

Then I went to speak with the financial planner, who detailed more of the insurance process. I did ask for self-pay prices in case insurance doesn’t work, and she provided that.

Now, before I give you numbers, my hope was $8,000 total. Lee and I know we can handle that. My nightmare was $13,000, since that’s what I half-way expected after reading what everyone else has paid for similar procedures on the OH boards.

Their price for the May brachioplasty would be a total of $5,265. With a second surgery discount, the late June breast lift would be $5,400. That’s $10,665 total.

Now that’s more than expected, for sure. But having it in two stages would mean two extra months to save, which means it just might be okay. Lee says don’t worry about how much it costs, just get it done because it needs to happen. That’s my boy!

So I’m left with the following thoughts:

  • Would another surgeon be able to do both procedures at one time, saving on facility fees? And two separate leaves from work?
  • Lord, please work a miracle and have insurance cover this!
  • Can I really handle two surgeries 6 weeks apart? That sounds insane!

So my plan is this:

  • Get the labs done that Dr. Albear ordered so that we can find out if there are any problems
  • Call their insurance coordinator back in 2 weeks to check on the insurance status
  • Reschedule all of my March consults for January/February so I can know what my other options are and make a decision. I hate leaving things open-ended
  • And once that’s done, I’ll work with whomever to establish an actual surgery date(s)

Getting closer to plastics feels really good–like I’m that much closer to having a normal, healthy body!

Preparing for the Flab

So I had it penciled in on my Franklin Covey planner that I needed to call my insurance company and ask about skin removal coverage.

I don’t have procedure codes, I don’t have a ton of medical information. So, like a dummy, I basically just asked, “um, hi, can you send me the policy bulletins on skin removal after gastric bypass?”

The girl couldn’t really answer my question because it isn’t explicit in my policy. She looked up my bariatric benefits and said that my policy does include pre-op and and post-op care (duh) as well as reconstructive surgery. Well now that’s good news.

I asked about the panniculectomy since it seems to be covered most often, and she read the policy to me. Something about having to be documented in the medical record that there’s rashing and chafing that it reoccurs over time. So I see a million visits to my dermatologist or primary doctor in my future.

What I really know I’ll need is a brachioplasty. My arms already look like they belong on somebody three times my age, and it’s only getting worse.

Anyhow, the girl said it would be wise to talk to my doctor, get procedure codes, and call back. What I’ll actually do is research procedure codes on the internet, and then call them back once the new benefit year starts April 1st. I’ll consider this Cosmetic Surgery Plan of Attack part I. Other elements of the plan:

  • contribute as much as I can to pre-tax medical savings accounts for what won’t be covered
  • exercise and lotion. exercise and lotion. exercise and lotion.
  • vitamins and water. vitamins and water. vitamins and water.

And so if I start planning for this now, perhaps I won’t have to wait quite 10 years for approval once I’m done losing weight! (which feels like it may be never, by the way. I am losing so S L O W L Y!!!)

Insurance Surprise

With all the trouble I had getting documentation for approval, I half-expected my insurance to reject the claim for my hospital stay and surgery. I’ve just heard too many horror stories about approvals followed by years of appeals and lawsuits. But I’m happy to report that BCBS has paid both the hospital and my surgeon, no questions. A true blessing, methinks!

I HAVE A SURGERY DATE!!!

Finally!!  They offered me January 15th, which is my mother’s birthday. I can’t ruin her birthday like that, so I opted for the 16th instead. Woohoo!!

The 29-day countdown is ON!

Hilarity Ensues

Well, I don’t have to wait on that faxed letter after all. It was in the mailbox when I got home yesterday. And guess what? IT’S ANOTHER FREAKING PRE-CERTIFICATION FOR AN IN-PATIENT HOSPITAL STAY. Not what I need. Frustrating, yes?

I know I’ll have to fax the letter to Odalys since she hasn’t received her copy yet. And I know it won’t be what she needed, and I’ll have to keep working on it.

So to be proactive, I went ahead and called BCBS on my drive to work this morning. I spoke to Felicia in Benefits and explained what I needed. Toward the end of the explanation, she said, “I’m sorry, but I just have to ask, what does your surgeon hope to gain by receiving this letter?” I said, “Frankly, I don’t know. I just know that I can’t have surgery without it.”

She put me on hold. For like forever. Then we she came back, she said, “How does this sound?” and proceeded to read the following:

Dear Ms. Griffin,

Thank you for your recent inquiry concerning benefit coverage for Gastric Bypass. It would appear that based on the information previously reviewed by medical review Ms. Griffin has successfully completed the criteria outlined in Medical Policy G-24 and has been approved for the bypass procedure.

Our records indicate that Gastric Bypass is an eligible procedure according to the patient’s Group Medical Plan.

If we can be of further assistance, please contact us as the number listed below.

The letter was on my desk by the time I arrived to my office at 9am. Now that letter, combined with the pre-certification letter for an inpatient admission at Ocala Regional Medical Center for 01/09/07 for provider Muhammad A Jawad ought to have this crap covered.

I faxed the info to Odalys and asked her to let me know if this meets their criteria. I have confirmation that she has received the fax, so now I’m just waiting on a call back. Let’s hope this is the end of the line!

Dang Christmas Cards are Slowing My Letter Down!

So the approval letter that’s supposed to include the procedure code, facility, doctor’s name, etc was supposedly mailed last Tuesday, December 11th. Problem is, nobody has seen it yet.

I called Odalys, she already checked today’s mail but the letter wasn’t in it. So I called BCBS to see if they could fax it, but the dude Jim said he doesn’t have access to the letter “since he’s in pre-certification.” I said, “ok, well who does have access to the letter.” He says, “Benefits.”

So I hang up. When the prompts come on, I yell “BENEFITS” since the stupid voice recognition software doesn’t understand anything I say unless I yell (so much for privacy… sorry coworkers). I spoke with Danielle who said, “I don’t have access to the letter either, but I can contact the department that does. They are already closed for the day, so it probably won’t be faxed until tomorrow.”

So maybe the letter will be faxed to me tomorrow, in which case I can fax it to Dr. Jawad’s office. And let’s just pray the letter really does include all of the information Odalys needs to give me the green light for surgery.