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Medical Geek Speak

Geek Speak.  It’s when someone vastly more intelligent than you starts explaining something detailed and complex and usually since you have about zero interest in whatever the topic of conversation is, you aren’t really paying attention and hence it goes right over your head. The speaker is talking in “Geek Speak”.

Now sometimes this happens because you are not familiar with the entire process of whatever is at hand. In my case last week, it wasn’t so much that it went over my head, it was clearly that I did not have a glossary to identify the meaning of certain words when applied to the medical field, medical insurance, and the completely incomprehensible process of medical billing.

Dealing with my insurance has been my biggest obstacle in my journey to weight loss surgery. When I first approached the idea of a gastric bypass on what will soon be four years ago, my insurance didn’t even cover bariatric surgery. Or should I say, my husband’s insurance didn’t. It’s funny really, of all the companies that I expected to give us the best medical benefits I thought it would be our Union for sure. Since with most Unions the Membership decides what they will and will not include on medical insurance policies you would expect that they would make pretty good decisions. The fact that most medical insurance companies today won’t even cover bariatric surgery amazes me. When I add up what they would be saving over the course of five years in diabetic supplies and doctor visits alone makes no sense, and those calculations are based on someone like me, who is not a critical diabetic.

Once our Union did add bariatric coverage, it left a little to be desired, but with most insurance companies not really covering it at all, I can’t complain too much.

So, when this happened, I suppose that in truth I was at the end of my rope. I’d been talking with the insurance company for days trying to decipher what benefits they would pay based on the wording of the policy. Which mind you is almost as fun as having your teeth pulled, and getting answers is just as easy.

The weight loss surgery coordinator at SWMC had called me to explain what she found out when she verified my insurance.  I was expecting this call, and excited to get the new, because after this the next step was finally my first pre-op appointment. But as she started to explain what the insurance would cover and what I would be responsible for, I started to panic.

She told me what I expected at first, the insurance would not pay for anything pre-op, nothing post-op, they would not pay for any complications that arose from surgery, they would only pay on the surgery itself, and only if the surgeon, anesthesiologist and hospital were all part of their preferred network. Then she explained to me that my insurance has a $25,000 maximum lifetime benefit. So what that would mean for me was that after the surgery, they would bill out to the insurance, the insurance would pay 85% of the cost of the surgery up to a maximum of $25,000 and then I would be responsible for the rest.

She told me that typically surgeries bill out at anywhere from $30,000 to $60,000 and that they really have no way of knowing what it will bill out at because it all depends on how long you are in the operating room and how long you stay in the hospital after surgery.

I panicked. In fact, the fear of god set it. I understood what she had told me to mean that depending on how things went the surgery could cost anywhere from thirty to sixty thousand dollars and my insurance would pay twenty-five thousand of that and then I’d be accountable for the remainder, which from her estimate could be anywhere from five thousand to thirty-five thousand.

I felt like I had just walked into a casino in Lost Vegas and was about to roll the dice at the craps table. What I didn’t understand, was why if my insurance was involved the surgery cost somewhere $30,000 – $60,000 but if I chose to finance the surgery myself or chose to cash pay, there was a flat rate cost of $30,000. At first I thought it sounded a lot like “We’ll take the money your insurance pays, but we’re going to make sure we get some from you too,” and I was notably upset.

Over the course of the next few days I went through a huge emotional roller coaster, thinking that once again my surgery was unattainable.  I tried to get financing for a cash pay surgery and got declined over and over, not because I don’t have the credit score or the income, but because I am self employed and for some reason lenders hate us self employed people.  When the outcome looked bleak I started investigating something I probably never would have considered before, but desperate times call for desperate measures. I started looking into Medical Tourism and the prospect of having my surgery performed by a surgeon in another country. I started looking into programs that offered bariatric surgery for much lower cash prices in countries like Mexico and Israel. I’m sure I will talk about Medical Tourism a bit more later, because honestly I find the entire thing interesting and I can easily see how it would become a prospect for people that are facing similar situations as the one I thought I was in.

However, I wasn’t in any situation, I simply didn’t understand the situation I was in and had gotten lost in the medical mumbo-jumbo version of geek speak.  When the weight loss surgery coordinator said the surgery could bill out a anywhere between $30,000-$60,000 she meant something completely different than I thought.

When they say a procedure will “Bill Out” at a certain amount, they are talking about the bill that they send to the insurance company. They are not talking about the “Contracted Rate”.  What this means is that the medical insurance may get a bill from the hospital for let’s say, $42,000. The insurance company then adjusts that bill to the contracted rate that they have with the hospital. So basically they say, -Okay you billed 42,000 but we are only going to allow $20,000 of that because it is our contracted rate, so they adjust the bill to, in the case of our scenario, $20,000, disallowing $22,000 of the charges that the hospital billed them. Now, after they have adjusted the bill to their contracted rate with the hospital, they pay their part, so in my case they would now pay 85% of the $20,000 that they allowed. So that means the insurance would pay $17,000 of the $20,000 they allowed, leaving me responsible for $3,000 left over. Now if that was just the hospitals portion of the bill, then the same would happen with the surgeon and the anesthesiologist, and my insurance would continue to pay each bill in the same fashion until the $25,000 lifetime maximum had been exhausted.

Once this was all explained to me by the weight loss surgery coordinator at SWMC I felt a lot better. In fact, I felt like the weight of the world was lifted off my shoulders because I had been on an emotional roller coaster for days thinking I had come to the part where I find out it won’t happen again and that sort of disappointment would be pretty hard for me to handle at this point.  The weight loss coordinator for SWMC felt pretty bad that I had misunderstood what she said and she took the extra time to help me understand a bit more by taking the time to give me an example of how one of the surgeries had billed out when the insurance company paid out very similar to mine and also had a maximum benefit. The patient in the example she gave me ended up paying less than $5,000 out of pocket when all was said and done.

Yes I felt A LOT better. Now if only we could start taking some steps forward, the last month has seemed like a stalemate and I am just so eager to progress. Of course it was during that conversation with the weight loss surgery coordinator at SWMC that we found a discrepancy in what my insurance company told them they would pay and what they told me they would pay, so before we can move forward we have to get that cleared up. So welcome to my world of more waiting.

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Author of Desperately Seeking Slender
Jaime "Pandora" Williams

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