PacifiCare Came Through---YAY!!

L8BloomR · 10-05-2006, 02:28 AM

Hi!! I am sooooo excited!! Last month I posted about how upset I was with my insurance co., PacifiCare. I was motivated and had preliminary approval for surgery, when they suddenly demanded I do a 6-month online "diet" program before they would give final approval. I tried every which-way to get them to reconsider, but was told "no exceptions". But suddenly yesterday, out-of-the-blue, I got the final authorization in the mail, and today I got my surgery date----YES!! :clap2: I will become an official Member of the Band on Nov. 8. I can't wait! LBT has been so inspirational to me and I have loved hearing all the success stories. Thank you all for the wonderful job you do of sharing and encouraging... I hope to finally give back some of it when I start my Band journey to a better life. Soon!!
Karen (I can't stop smiling!):dance:

**Jack** · 10-05-2006, 08:50 AM

GREAT!!!

PacifiCare was my carrier also, 2 years ago. In my area they dropped the Band coverage in 2005. I don't know what 2006 contract does, they continue to pay my fills/OV except for my co-pay.

L8BloomR · 10-05-2006, 10:25 PM

Thanks Jack. I'm glad to hear you are still having a good experience with PacifiCare, since I thought I was told that they will only pay for fills and OV for the first year after surgery. I guess I will just wait and see, since they surprised me (pleasantly) this time! How are you doing with your band? I still don't understand all the LBT lingo... you have a "w/o" weight. What does that mean?? It appears you have done very well--- Way to go!!

**Jack** · 10-05-2006, 10:43 PM

L8: you'll get up to speed here quickly enough....and I'm the ONLY Bandster I know with a 'w/o' weight....I'll tell you someday what it means.

I've frankly been surprised at what PCare has done for me....my regular clinic staff did NOT do Bands....so I had to go 100 miles north 'OUT of net' to the closest surgeon....and we even found a way to help them make a good decision....

My estimate on what they save WITH me being banded, on just not taking my meds alone, is they will probably be seeing a savings about the 4th or 5th year postOp....

and more to the point, I probably won't be stroking out, etc....due to improved everything....

Congratulations on your sucess.....keep up YOUR good work...

L8BloomR · 10-05-2006, 11:01 PM

Ok, I am going to hold you to your promise to tell me "someday" what a "w/o" weight means!!! :heh:
That was wonderful to hear how much PacifiCare has done for you. I now feel kinda guilty for being so upset with them at first! They really have done alot lately to try to help. The only thing I wish they would have done was allow me to go to a surgeon closer to my home (there a several excellent ones). Instead I have to drive 3 1/2 hours, through horrid traffic, to get to the doctor and hospital I will be using for the Band surgery. sigh. But I am so excited to be having the surgery, I will gladly drive through fire!!
Thanks for being there!!
Karen

Penni60 · 10-06-2006, 01:23 PM

I have Pacificare PPO and was told they do not cover the band but might cover the bypass. Can you guys tell me whether you have a PPO plan or an HMO plan?

L8BloomR · 10-06-2006, 02:26 PM

Hi Penni,
I have PacifiCare HMO. I was told that the PPO side does not cover the LAP-BAND^®, which makes no sense to me but.... Sooooo, maybe you could switch to the HMO side of PacifiCare? The PPO does cover gastric bypass, just not the LAP-BAND^®. Good luck and let us know what happens! And I must say PacifiCare has redeemed themselves in my eyes... they are paying a good part or all of virtually everything I have to do for the surgery, which makes me feel bad about my initial complaints about them. :embarassed:

Dutchgrl59 · 10-14-2006, 08:24 PM

I have Pacificare also and as my list describes I have jumped thru plenty of their hoops and they just keep adding on more. The straw that broke the camels back was their 6 months telephone bariatric program. I still don't see the reason for that. Anyway..... I hired an attorney and just hope that my journey turns around. Still hoping,

L8BloomR · 10-14-2006, 08:35 PM

Patty, do you have the HMO or the PPO PacifiCare plan? Only the HMO will cover the LAP-BAND^®. What was the reason they denied you---because you haven't done the stupid 6-month diet thing? :( It appears that they already cleared you enough to pay for all the other requirements...which they will have to have you re-do if they make you wait for another 6 months, so I don't get it. Or did YOU have to pay for the psych evals, etc.? There must be more to this... Can your doctor help you get to the bottom of it?
Karen

sunflower · 10-15-2006, 02:44 AM

Yes, I have been denied follow up care here. They keep sending papers and papers with no no no, I'm very frustated with them, although I did hear that they provide a patient advocate on the phone. I don't know but I feel frustrated too. I'm going to have to deal with this tooth and nail. This is after I have told them I have already had the surgery and all I want is aftercare here. I know someone who gets aftercare and has Pacificare but I don't know if she is a PPO.:guess

Sunflower

Dutchgrl59 · 10-15-2006, 12:25 PM

Karen,
I was approved for the surgical consult. When my doctor told insurance that I was a candidate for surgery and that he was ready to do the surgery, thats when they came back and said that I needed to do the telephone program! At that point I thought, OK what if I lost 3lbs on the telephone thing.... then they say "she doesn't need surgery" or if I don't lose anything then they will come up with some other hoop for me to jump thru. What a game! Yes, I have the HMO but insurance will do everything in their power to deny patients. My doctors office has been wonderful and have placed appeals for me during this last year. I trust them. What I understand is that Pacificare purchased an "off the shelf" insurance plan which includes weight loss surgery as an option, but because they don't really want to give away that product they manipulate patients in order to NOT give this type of surgery. This saves them money. I get that. What I have also discovered is that this is not a hard and fast answer and there are indeed patients that have been covered by Pacificare and have gotten LAP-BAND^® or GBP where clients are persistant. And that is where I find myself. Yes, you are indeed lucky to have gotten thru the maze pretty much pain free, unfortunately that is not what appears to happen for everyone. My story isn't abnormal, it's typical. I was not surprized. Now, I need to let my attorney support me.

L8BloomR · 10-15-2006, 11:42 PM

Patty, did PacifiCare pay for the psych evals and the dietician visits? If they put you off for 6 more months, they will have to pay for these things all over again, since I believe they would have to be done closer to the surgery date. I would think also that the blame is with whoever authorized your visits (at PacifiCare), because you should have been doing the 6-month diet while you were undergoing all these visits. I don't think they will deny you the surgery if you do the diet because I think they will have to justify why, if you were enough of a candidate for them to approve all the "hoops", then you should still be one after you go through them! I think they throw the diet in there to try to get you so irritated you pay for the surgery yourself. I was told the diet thing was a new requirement that only applied to insurance plans that were renewed after July 1 (I think that was the date) and that others renewed earlier were exempt. Could you find out anything about that? Good luck, I know how frustrated I was when I heard about the diet and I am not sure why mine got suddenly put through without it. It seemed like once I signed on to it and gave all my info, they approved me. Maybe that would work for you? Keep me posted!
Karen

L8BloomR · 10-15-2006, 11:45 PM

Sunflower, you are freaking me out! I never thought about whether the after care was covered by insurance! I just assumed it would be! Did PacifiCare pay for your LAP-BAND^® surgery or did you have it done through someone else? Maybe they don't want to approve the aftercare if they didn't approve the surgery? Good luck with your battle and please keep me posted!
Karen

janiee · 11-07-2006, 03:18 AM

L8BloomeR,
May I ask about the 6 months diet program that they almost made you go on? I have Pacificare HMO and I think they are going to put me on something called "Healthy Roads"for 6 months. Have you heard of this?What is it? I am so excited to start this process, but everything is going so slow already. I just want my band!!!WaaaaaLOL!!! Waiting is not a forte of mine..hehe

L8BloomR · 11-11-2006, 12:47 PM

Janiee, I am so sorry I couldn't get back to you until now. I was banded on the 8th, and didn't get home until last night. Oh, and I am doing just GREAT, so whatever you have to go through to get this done, it will be worth it! Yes, Healthy Roads is the thing they make you do.... what a joke. An online diet that you only have to sign into once a month, and give your weight. Oh, and pay $25 (if I remember correctly), and they send you a diet book!! Stupid, stupid... I don't know too much about it, because 2 months after I started the thing, I suddenly got my authorization and was on my way! So, maybe they are just wanting you to appear to be motivated, or maybe it was something else in my case, I don't know. I agree---it is hard to wait once you make the decision and being told to wait another 6 months is rediculous!! My advice would be to start the process, sign up with Healhty Roads, do all the tests and classes, and make sure your doctor lets them know how many diets you have been on and any current health issues you have that are being impacted by your weight, and maybe they will "see the light" and get on with the authorization. I will say that if you can wait, it is worth it to not have to self-pay. I had to spend an extra day in ICU due to some breathing issues and if I was doing a self-pay, I would probably be needing to sell my house to pay the bill! PacifiCare was very good once things started rolling. I do believe they tried to cover every base to make sure I was going to be successful, and I have to give them credit for that. Good luck, and please keep in touch with me about your progress! It is worth it!
Karen