Question:
I called Medicare and they said they do not pre-approve.
Has anyone had a problem getting Medicare to approve WLS? I really don't want to go through the whole preop process only to have them refuse to pay. I have Anthem BCBS as a secondary insurance. They said they will pay if Medicare pays. Thanks for any help you can offer..MJ — Mary Jane C. (posted on August 27, 2003)
August 26, 2003
medicare does not pre-approve. My best friend had it in Nov. and the
surgeon did all the testing and took her medical history (which he, not
medicare) required and also turned in her medical history. When the
testing was done she had her surgery and there was no problem with medicare
paying. They used his records and her medical history(which was bad) and
determined that she was medical mecessity (after her surgery was done.)
All she had to pay was 800. to the hospital and 400. to the surgeon. None
of it was upfront. They billed. Medicare paid nearly 30,000. dollars. I
had surgery in feb with medicare as my secondary and also did not have a
problem or have to have pre-approval. Medicare is federally funded so it
is the same in all states. Some say they are now requiring a 5 year diet
history but If they are, they have changed it. You shouldn't have a
problem if you have co-morbs and are found by your surgeon to be medical
necessity. Good luck.
— Delores S.
August 27, 2003
Hi MaryJane, My mom has medicare too and they told her that they do not
preapprove any type of surgery you hav edone that is just their policy. But
htey are good about paying afterwards. My mom just had knee surgery a
couple of years ago and they paid for everything including physical therapy
afterward it was all done! So, now she is trying to have this surgery done
and they told her just to go thru all of the process then after surgery her
doctor will submit all of the papers then they should take care of it all!
I also know other ppl who have medicare and wasn't preapproved beofer hand
then had the surgery done and they paid for everything too! So, don't worry
too much you should be fime but one thing you need to find a surgeon that
will do the surgery before knowing if he'll be paid or not cuz some don't
like doing it that way, but if you find the right one then they'll know
that medicare will pick up the bill afterwards. So good luck to you and I
hope this eases your mind some!
— Melodee S.
August 27, 2003
Everyone is right Medicare doesn't pre-approve but usually will pay, the
problem some are having where I live is that they don't pay anywhere near
what they are billed so many of the surgeons won't accept it anymore, and
some are down to one patient per month per doc.....I really feel bad for
those that have to wait so long....Best Wishes!
— Saxbyd
August 27, 2003
Thank goodness my doc accepts Medicare or I would still be pre-op. It is
very true that medicare won't preapprove the surgery. As mentioned, the
hospital submitts all the paperwork and then medicare either pays it or
they don't. I just received some of the statements from medicare stating
what they paid and boy they barely paid a third of the billing rate, but my
surgeon's office new that ahead of time, so I guess I'm one of many of
their charity cases. LOL. Now it time to wait and see if I'm going to
receive more bills for my share. Some doctors don't bother to bill me for
the co-pay and others do. It's wait and see now as to whether or not I'll
have to file for bankruptcy. Oh well, at least I'll be a able to fit the
regular size inmate uniforms.
Good luck in your journey.
— Rosa F.
August 27, 2003
I too have Medicare. I had my lap RNY June 11, 2003. Some of the major
medical centers near me would not accept Medicare patients (their exact
words--<i>they do not pay enough</i>. Their policy is to pay
for bariatric surgery when the physican deems it necessary. My surgeon
said "No problem, they always pay." And they did. My secodnary
(Tricare) picked up the balance, so I had to pay absolutely nothing. Good
luck!
— Linda S.
Click Here to Return