Self Pay and later Complications

[Kukla]

Hello,

I am still pre-op, and plan to get sleeved mid July... have my second consult with the doctor I chose next week.. and after that final decision time...
Although I have insurance, that covers WLS, but required the 6 month process, I have no patience for that.... I decided to be a self-pay, as the doc only charges 10.5k ALL Inclusive (here in Florida).

My question is, if here are complications later on, for example a leak, which is directly related to the sleeve surgery, and can happen up-to 3-4 weeks after the surgery, would you know if the insurance company will cover it ? -OR- those expenses must be paid out of pocket ?

It so happens to be that the surgeon I'm going to, believe it or not, has a PERFECT track record, he said in my first consult he had ZERO complications.... and indeed has been very much recommended by everyone I spoke to. I did a lot of research on him... all feedback is outstanding ! the center/hospital, where he does his surgeries, is an excellence center... so everything looks really good !

I will of course pose that same question to him, when I see him next week, and will 'come' back to update, but also wanted to know what did you think...

Thank you in advance...

[tinman]

Those are all great questions. I too was a self pay. I elected to go to Mexico. One of the main tipping points for me was the fact that the surgeon I chose had done literally thousands and thousands of the VSG's. To me, it seemed like no matter what happened to me on the table, this guy had seen it, dealt with it and probably had a good plan of attack. In other words, no hesitations.

The day of my surgery, I was the second one of the day. He literally did 14 VSG procedures that day. When I got up to walk during the night, he was still at it and didn't stop until 2:30 in the morning. He did my procedure at 9:00 the previous morning. It really isn't unusual for a surgeon to stay in surgery 12-14 hours at a time. Brain surgeries routinely take that long. I'm not sure I would advocate doing 14 surgeries in one day, but, that's how this guy rolls and his experience was the main selling point for me.

Good luck to you. Ask lots of questions. The more info you have pre op, the better off you'll be post op.

[Sleeveless in Seattle]

Insurance will not pay for complications resulting from the surgery. My surgeon included 3 months of BLIS insurance which covered leaks for that time and also infection but that is it. My insurance would not cover the procedure period, if I had the option you had I would definitely do the 6 month process. Mine was almost 3 months from my consult with the surgeon anyways in that time I did my stuff the surgeon required: nutritionist visit, psych visit, endoscopy and pre-op diet. That is kind of strange that your surgeon claims no complications ever. I wouldn't bank on that. Even the best of surgeons generally run 1% complications and you don't want to be that 1% and have to pay for it out of pocket.

[SDmom2two]

make sure you get the answer in writing. If there are complications, you may be told you have a pre-existing condition.
The flip side from what I know of the good surgeons with good track records is that the complications are very low and infrequent - much is in your court ie making sure you follow the food plan. Dont do like on "my 600 lb life" where they are driving through fast food a week later. Good luck!

[Paulette21]

My insurance would not cover the sleeve procedure nor will they cover any complications as a result of the sleeve surgery.

[Kukla]

Thank you everyone... I will sure to discuss it with him next week ...

Will let you know.

[Mrssimpson]

You must have chosen dr shillingford. He is incredible !!!!

I loved my experience.

[jessiejess]

Have you thought of asking your insurance company this question? Seems like the best thing to do is just call them. Your surgeon isn't going to know what your plan covers.

[Kukla]

Have you thought of asking your insurance company this question? Seems like the best thing to do is just call them. Your surgeon isn't going to know what your plan covers.

Yep.. good idea... will do that as well.

Thank you

[mrsjoe]

Definitely ask your insurance. I was in a similar situation to yours in that my insurance covered the sleeve in general, but I didn't qualify because my weight was too low and I didn't have any life threatening diseases. But, I was happy to discover upon calling them that even if I self-paid for the surgery, any complication would be covered because they would be deemed medically necessary.

We even discovered that the insurance will basically cover everything around the surgery even without approval. They paid for my surgical consult, my pre-surgery labwork and my post-op office appointments. If your insurance does that, maybe you can negotiate an even cheaper price? I am due a refund from my surgeon's office because I paid the full price, not knowing all that would be covered. Granted, it's not a big refund, just because the surgery itself is the big cost, but it was such a relief to know that any complications would be covered without having to spend the $2700 for BLISCare.

[Kelli D]

Dr. Shillingford was my surgeon almost 1 year ago and did an amazing job! I haven't had 1 bad day yet!! Best of luck to you!!

[Batmanswifeislosing]

I am not positive but I believe with WLS it depends on if insurance paid for it, what I mean by that is if your insurance does cover it and you self pay as to not go through psychiatric classes and nutrition counseling and such all to avoid waiting then I am pretty sure they will NOT cover the "complication" should one arise because they did not approve the surgery and you did not follow their rules etc.
Now if they cover it and you go through their steps and they decide that you are mentally, and physically ready and educated enough and they pay for the surgery, then after that I am 99% sure they cover the complication if it arises.
If insurance does not cover WLS and you self pay and there is a complication that the doctor deems is DIRECTLY related to the surgery then almost always they will not cover it. However if it was something where you went to the ER and don't specifically write down that this problem is for sure related to this surgery then it can slip through.

I self paid in Mexico and had the issue that my incisions opened after I removed the stitches (probably should have left a few more days but was impatient) I went to the urgent care in town, they saw me, and just wrote it up as an opened wound but made no mention of my WLS so my insurance covered it. However I went to my PCP to get a yearly check up and run blood work to check all the cholesterol, vitamin etc etc stuff and she wrote down that it was a blood check for post WLS care and my insurance denied my claim to pay for the blood work and office visit. My PCP physician and I have since talked about that and it was resubmitted and paid, because I was in fact there for my regular every year once a year routine stuff. I was not having issues, was not concerned about any levels or anything like that. I would have had the same testing whether or not I had the surgery. so just keep that in mind.


Also ask your insurance if you were to self pay if there could be any reimbursement later as I have seen and heard of it happening sometimes.
Good luck to you

[Kukla]

THANK YOU !!!

I spoke to the insurance company... they wouldn't give me a black-or-white answer ... because they DO cover WLS.. fully, and the DR. that I intend to do it with is 'on contract' with them, and is a recommended one.
If I were to go thru them I will qualify for sure because my BMI is over 50 without any medical issues.

When I posed the question about complications, if & after selfpay... they were baffled... but did say that since they cover WLS to begin with, with a Dr. that is part of their network, any issues (if marked that are direct derivatives of the WLS) will be subject to the approval process.... which I qualify for anyway... but will take longer to get re-funded

My company is Aetna with what seems a very good coverage... my out-of-pocket will be $1000 at most...

With Dr. S. track record (excellent) the center is Bariatric excellence and all this info... I should be OK...

mrsjoe, I have a repeat consult with my Dr. next week, I will ask about your 'idea' of a 'lower price'.

[Kukla]

I am not positive but I believe with WLS it depends on if insurance paid for it, what I mean by that is if your insurance does cover it and you self pay as to not go through psychiatric classes and nutrition counseling and such all to avoid waiting then I am pretty sure they will NOT cover the "complication" should one arise because they did not approve the surgery and you did not follow their rules etc.
Now if they cover it and you go through their steps and they decide that you are mentally, and physically ready and educated enough and they pay for the surgery, then after that I am 99% sure they cover the complication if it arises.
If insurance does not cover WLS and you self pay and there is a complication that the doctor deems is DIRECTLY related to the surgery then almost always they will not cover it. However if it was something where you went to the ER and don't specifically write down that this problem is for sure related to this surgery then it can slip through.

I self paid in Mexico and had the issue that my incisions opened after I removed the stitches (probably should have left a few more days but was impatient) I went to the urgent care in town, they saw me, and just wrote it up as an opened wound but made no mention of my WLS so my insurance covered it. However I went to my PCP to get a yearly check up and run blood work to check all the cholesterol, vitamin etc etc stuff and she wrote down that it was a blood check for post WLS care and my insurance denied my claim to pay for the blood work and office visit. My PCP physician and I have since talked about that and it was resubmitted and paid, because I was in fact there for my regular every year once a year routine stuff. I was not having issues, was not concerned about any levels or anything like that. I would have had the same testing whether or not I had the surgery. so just keep that in mind.


Also ask your insurance if you were to self pay if there could be any reimbursement later as I have seen and heard of it happening sometimes.
Good luck to you

========================

Thank you ... will Do !!

I thing I should be OK !

[mrsjoe]

Congratulations! I know for me, it took so much stress off knowing that the complications would be paid. I too have Aetna. I think so many people either have weightloss surgery excluded completely, which also excludes complications, or go through the approval process, so complications are automatically covered. We are just in a unique situation to have coverage, but not be able to or not want to use it.

Good luck with your surgery. Here's hoping you never need to get any complications approved!