Tips and Tricks

Thread Starter  

Hi all...I know this thread may be offensive to some and I apologize if it is. However, trying to meet all the requirements can be near to impossible. I've read responses to people asking for quick help to meet a certain insurance qualifier and thought we might as well acknowledge the elephant in the room and it might be helpful to share our info.

1-I've heard of people wearing clogs to weigh and loose pants so that during height measurement, you can bend your knees slightly. If you have this done at the banding office, they're not watching you too closely and they don't have prior records of your height.

2-For the psych eval, I told the truth but concentrated on how portion control was hard because I was physically hungry all the time.

3-For sleep apnea, you have to have a pretty high number to have it considered a co-morbidity. I heard it helps to take 3 benadryl before and not say anything about it. From personal experience, it IS difficult to sleep with all those wires and mess on so maybe it's just an evening out of the playing field.

4-I heard a person say to a friend of mine (who had to fudge a few things to get insurance approval) 'I hope you're happy. It's thanks to you my insurance costs are so high.' My friend's response was great. 'When is the last time your rates were lowered or you got a rebate because you DIDN'T use your insurance? Oh...never? I rest my case.'

This may be a justification but Fibromyalgia, bulging discs, bone spurs and joint pain aren't considered co-morbidities but make your life hell. So, I don't feel TOO horribly bad for thinking about 'enhancing' a result or two for a positive end. Besides...your med costs and RX costs are going to go down so your Insurace company benefits in the end, right?

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I heard wear loose pants and use ankel weights, and hey this thread don't offend me, people pay alot for their insurance so heck use it.

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Banded by Dr. Rudolf Weiner -Frankfurt, Germany

This is insurance fraud!!!!!!!!!!!!! If you get caught you face not only fines but imprisonment. I work for an insurance company and it is looked at very closely. It may not bite you when you get it approved, but the company can audit your case and take away any money it paid and press charges for insurance fraud.

Crystal Carter, RN

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But how would the insurance company know? They can't verify anything after the fact b/c the patient would have lost weight.

Again, I'm not justifying cheating...but you make it seem as if a rep from the insurance company will be there during your exam.

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Surgery Date 09/15/08
Starting Weight: 231
Current Weight: 211
Goal Weight: 140

First Fill: October 28th...5cc's

They can request all of your medical records from all of your providers to verify the actual information. If they have any inkling of suspicion they will demand a full refund and file charges.

Just because you got approved for a procedure does not guarantee payment. It is just a certification of medical necessity.

You can justify it all you want but it is still illegal. If you don't answer to it now in this lifetime, you will have to answer to the higher authority. Thou shalt not steal, and lying to get an approval is stealing.

crystal carter rn

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Thread Starter  

I'm sorry you disapprove, Crystal. However, I take umbrage with your accusations of 'insurance fraud' and paraphrased biblical quotes.

While I personally qualified with a 36.2 BMI, people that sit on the borderline of being able to qualify should not be accused of insurance fraud by fudging a result here or there. It's not as if they were a size 6, decided they wanted a LAP-BAND^®, and gained 100 pounds in a short time in order to qualify.

Insurance companies are programmed to behave in a fickle manner when it comes to honoring their own language and their medical personnel who receive bonus' on how many claims they're able to deny. My husband, who hasn't been to the Doctor with the exception of physicals for 20 YEARS, is charged the same premium that I am. In 10 years, I've had 3 back surgeries, chronic pain conditions, high cholesterol, 6 MRI's, a CT Scan, 2 CAT scans, 3 children and a hysterectomy. It would seem that my husband is owed a refund.

I'll let you know when that check arrives.

If you want to go down the straight and narrow, then who's to say that you and I aren't committing insurance fraud because we can't stop eating and we're too lazy to exercise? We didn't just 'come down with fat'; this is something we cultivated for years. Now, we ask for an expensive procedure to help us when all we had to do was put down the chips and pick up a carrot, right?

The ONLY reason insurance companies pay for weight loss surgery is because, in the majority of cases, the recipient reduces their medication intake and their health improves. I don't begrudge them their guidelines but if a woman finds herself ten or twenty pounds shy of an approval after being overweight her entire life, I'll be damned if I'm going to go to the moral stomping grounds.

Instead, I'll go buy a sister a box of Twinkies.

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I don't agree with the "Tips and Tricks" post. The measures and guidelines are in place for a reason. We may not always agree with them, but unfortunately, we don't make the rules - the insurance companies do. The height, weight, psych eval's, etc. are all monitored and set in place for very specific reasons.

I hope anyone reading this discussion thread will take into consideration the guidelines that must be met. I realize it can be quite difficult having gone through this insurance approval process myself, but I can't for the life of me imagine trying to trick my insurance company or my doctor, for that matter.

I guess what it all boils down to is whether you feel you're being ethical or not. If you can live with yourself cheating the system then that's your issue. Personally, stuff like this always comes back to bite me in the butt so I try to keep myself above-board. But...that's just me.

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Highest 320 lbs
Surgery 295 lbs
Current 268 lbs
Goal 170 lbs

I am sorry you feel that way. No matter what you say, it is still fraud.

I am one of those "medidal personnel" you think receives bonuses for justifying denials, however we are people of integrity and follow the guidelines. The Physicians always do a second review if we cannot approve a request. The nurses never give denials unless it is a contract exclusion. BCBS does not have to allow for WLS. It use to be an exclusion to all policies. I too was approved with a low bmi, but I had the appropriate co-morbidities. If don't begrudge anyone who meets the criteria to have WLS, but if you don't meet then you don't meet.

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If you aren't covered by insurance or you can't get approved then pay cash like I did! My insurance would pay for the surgery but I had to be on the plan for 12 months and I didn't want to wait! If you can't afford to pay cash, you can always take out a loan. Because with the money you save in medicine and food you will be able to pay back the loan!

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In my opinion it is also insurance fraud. Why take the chance of lying and being caught. Do you have children? If you do, think of how they will feel if you are caught and have to spend the next X amount of yrs in prision. If doing it for fear of not qualifing due to know co-morbids maybe this will help you.
I had my band placed august 18 of this yr. I had no co-morbids at all. No high b/p, so sleep disorders, no diabetes, nothing at all. Other than my weight, I was and still am in perfect health condition. My insurance aprroved me in less than 2 days. I only had to pay out of pocket $500.00.
No matter how you try to justify it, it is called stealing and fraud. Don't do something you may one day end up regreting is what my family has installed in me.

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Michele

Banded on: 08/18/08
First Fill on: 09/15/08
Second fill on: 09/25/08
3rd fill on: 10/07/08

Thread Starter  

Then we'll agree to disagree.

However, if we're going to split hairs, then when we have the LAP-BAND^® surgery, if we cheat on our doctor ordered diets afterward, is that fraud as well?

It just seems that we promised to do all sorts of things and to make all these changes, etc. So I'm assuming if you eat ANYTHING off your diet, be it a French fry or half a cookie, your pristine consciences will kick in and you'll jump on the phone to reimburse your insurance companies because you acted unethically. Right?

Hey...if we're gonna ride this white horse, then let's do it. No one gets cut any slack and no one gets a buy.

Crystal, I'm sorry you read contempt in my assertion that insurance companies provide bonus' to their medical personnel who deny claims. If that's not true, perhaps you should call Time and Newsweek, along with the NY Times, all who have done stories on the topic. I never said they behaved unethically. I said they look for every way possible to deny the claim. Insurance companies aren't bastions of goodwill. They are profit making entities. Period. However, if you want to argue insurance companies and ethics, I would suggest you read the cases of children denied last chance experimental treatments, people who lost everything after Katrina because State Farm worked like hell to find clauses to deny claims and the thousands of other stories out there just like these.

As for me, if I can help someone with my experience or relating things I've heard, then I'll do it. Since you don't agree, we'll see you on another thread.

Best Regards.

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I can agree to disagree. However cheating on a diet is not the same as leagally lying to your insurance company. You have no contract with your doctor to eat what they tell you, it is your on conscious.

And by the way, the newspaper companies also lie to gain a profit. They spread gossip and rumors. No one ever knows the whole story, they just give you what they think you need to know. I agree that it is sad that children cannot get experimental drugs depending on their policy, but the policies are for their own benefit. How do we know that the "experimental" drugs won't kill them sooner. If we pay for it then they will sue the insurance company because we paid for it.

Insurance companies are damned if they do and damned if they don't.

Crystal

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Thread Starter  

I beg to differ.

My doctor grilled me on my intentions. He forbade sugar, fast food and a host of other items. He made no bones about the fact it was a lifetime contract...you don't get to pick and choose which of your promises to honor. Did you just agree with your doctor verbally but since you have no signed contract, you feel you can pretty much do all the things they tell you not to? In my world, your word IS a contract.

Besides, in your earlier post, you made it very clear that lying is lying and there were no justifications. Ergo, cheating is lying and lying is fraud.

And according to the other poster, gaining ten pounds to meet a weight requirement can also get you prison time.

Sigh.

At any rate, let's allow this thread to die down and continue our ethics debate on another. I'm sure there are people who actually want to utilize the tips and tricks and I think it's misleading to clog up the thread with our prattle.

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It's fraud. Period. It is not "lying" or "exaggerating". Get caught and maybe go to jail and pay some serious fines. It seems like you don't want to hear that, but that's the way it is.

I think it's fine to have this thread and discuss it, as long as people reading it understand that doing some of the things suggested could get them in a LOT of trouble.

And no, I don't work for an insurance company. In fact, I hate my insurance company as I was denied for frivolous reasons even though I thought I had a good case. I just paid out of pocket, because it's the right thing to do and it's the best money I spent anyway.

You can be one of the good guys or one of the bad guys, pick one.

Thread Starter  

Again, I disagree. I hardly think gaining a quick ten pounds to meet a requirement makes you a 'bad' guy. How ludicrous.

What I 'want' to hear isn't relevant. I began this thread to help people who were asking questions on how best to make sure the requirements were met with their insurance companies. I certainly didn't expect the white knights to come galloping in and threaten people with jail or cast dispersion on their character. I find that appalling and if that makes you a 'good guy', I'll stick with the 'bad' ones since we aren't so deluded as to think life is merely black and white.

Now...the detractors have made themselves known and your disapproval has been registered. How about retiring so other people ('bad people', to you) can share our tips and tricks.

When you're done attacking those on this board, I hope you ride the white horse straight into Washington and take on Bush and his cronies for this pointless war, for lying to the American public, for all but bankrupting our country and killing innocent Americans, Afghans and Iraqis.

After, of course, you clear this thread of the horrible people who need a nudge to obtain a new life for themselves.

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