Has her doctor said that her skin can’t possibly tighten up on its own? How long has she been at her goal weight? I realize there are medical complications and her doctor approved it but it seems like an awfully expensive thing just to jump in to.
Generally speaking, doctors tell you to wait a year after you’ve finished your weight loss for your skin to recover. After that year, it’s as good as it’s going to get. Younger people have more elastic skin, older people less so. If her weight is considered “stabilized”, then it’s been at least a year since she reached her goal, and her skin is what it is.
This summarizes my sister’s situation perfectly.
It’s not going to tighten up.
And I’ll say this again, because people keep asking. Her insurance specifically excludes medically necessary surgery for skin removal. Will. Not. Pay. Under any circumstances. The policy is very clear.
IIRC, she did have an interview to change jobs and I think she even asked about that. I can’t remember exactly what the dealbreaker was, but I think it was the accumulated vacation time. At the new job, she’d have to work there about five years to accumulate the same amount of sick + vacation time to have a major surgery like that and be out for a few weeks to recover. There’s also the fear of the pre-existing condition not being excluded. Don’t know when the new law takes effect on that point.
You say you THINK it will be $50K. Has she actually asked the hospital to quote her a price or are you just guessing?
My daughter discovered, when she had her baby with no insurance coverage, that there were considerable discounts for paying in cash.
The “discount for cash” usually only works if you negotiate it in ADVANCE, which shouldn’t be impossible in this case. I regularly argued providers into providing a discount in the 30-40% range.
However, be prepared to discover niceties like anesthesiologists not being part of the group you negotiated with, substitutes during procedures who you’ll have to negotiate with after the fact, and automatic billing systems that charge you full price multiple times until you get it all sorted out.
My sister has hard numbers. I cannot keep track because it’s not me who needs the surgery/money. When I said I think, what I mean is, she has to have three surgeries. I believe they all add up to somewhere around 50K, so she wouldn’t need that all at once.
Anyone have any idea about the tax implications of accepting large amounts of donations? When people raise money for their sick kid dying of some dreaded disease, do they have to form a foundation to avoid paying taxes, or is that just a tax bite you have to account for?
In the U.S., gift recipients owe no tax obligation, no matter how large the gift, as long as it is clearly a gift with no expectation that you will render any service/provide any consideration in return. Gift givers may owe taxes if their gifts exceed certain limits (currently an individual can give $13,000 to each recipient without tax consequences). The reason people form foundations to receive donations is so that the givers can take charitable deductions from their income tax.
Gift Tax FAQ from the IRS
If you are going from Company Insurance to Company Insurance with <60 day break, you don’t have to worry about pre-existing conditions at all, regardless of the status of the new health care law.
Once she has worked at a new job long enough, you can always take FMLA leave as well (unpaid), if she doesn’t have enough sick time + vacation time.
She could never afford to take FMLA unpaid. I think that was the issue when she interviewed for another job. She has plenty of recovery time built up as sick + vacay time at her current job.
I have no doubt that the policy says this. But doctors and clinics often know ways around such exclusions.
For example: my health insurance policy specifically excludes treatment for TMJ. They claim they won’t pay under any circumstance for any treatment. I got TMJ and had serious resulting problems, with muscle pain and migraine headaches. My physical therapist was a specialist in TMJ problems. He told me he simply NEVER codes anything as a TMJ problem when submitting to insurance; he calls it “muscle pain” or “headache” because my insurance pays for those. I am now headed off to a TMJ pain clinic at a major university to get the problem fixed. They told me that they know what medical codes to use in order to ensure my insurance pays. They boast a 95% success rate in getting insurers to pay for TMJ treatment even when the policy specifically excludes it. Part of their success comes from calling the insurance companies and negotiating…even where the policies exclude TMJ treatment.
Why does an insurance company negotiate regardless of a seemingly clear policy exclusion? Because sometimes it’s cheaper for them to make an exception than to keep paying for maintenance treatments. In my case, physical therapy, migraine treatments, etc.
I think you and your sister should ask around to different doctors to see if you can find providers who knows similar ways around the prohibition against excess skin removal. Perhaps some who might call it “treatment of rash/sores” instead of “removal of excess skin.” Or who might call her insurance company and make a case for her.
This is an incredibly common practice, which is (I suspect) why people keep mentioning “working with the insurance company” despite the exclusion. We don’t have problems with reading comprehension; we just know that the system is not as black-and-white as it appears at first glance.
Thanks Q.N. The thing is my sister works doing the insurance billing for a physical therapy office. I would find it difficult to believe she’s not aware of this and hasn’t asked around already or we wouldn’t be at this point. It is possible, however, that she asked one doc, got nowhere, and assumed she’d get the same answer from everyone.
The other thing is we both know how insurance works. The employer determines the formulary, not the insurance company. I think her issue is with HR at work, not her insurance carrier. Regardless of that, though, it does make sense to doctor-shop. I guess I’m the one who’s being obtuse because with the old policy, she was working with a doctor who was coding things so that the insurance would cover it, but she had to have a documented trail of x number of treatments before they’d pay. So I don’t really get how a doctor can code a major body lift as “treatment for skin abrasions” and get away with a $35K surgery bill. I suppose it can’t hurt to ask, assuming she can afford a bunch of copays to see random docs…
She needs to talk to a bunch of people who specifically do excess skin removal. They will know what insurance tricks are available. (And yes, if her skin abrasions/sores get bad enough, removal of at least some of her excess skin would be reasonable and covered. Maybe not a whole body lift at once, but the affected area.)
Ultimately, once the employer buys the policy, the insurance company is who will decide whether they cover a procedure or cost. I know of many instances wherein insurance companies decided it was cheaper to make an exception and cover a specifically excluded procedure or cost after a doctor made the case to the insurer. If she can’t get her previous doctor to go to bat for her like that, maybe she can find another one.
I don’t know why she would talk to HR at work about it at all, unless she thinks she can convince them to buy a policy next year that doesn’t exclude excess skin removal.