Question:
Anyone with BCBS-Federal PPO that has experienced
Now I am not only thoroughly confused, but ANGRY and don't know who or what to believe anymore!! I was informed just now that I HAVE NOT BEEN APPROVED for WLS scheduled on Sept 3rd, and my claim will not "actually be approved" until AFTER the surgery and it is submitted to BCBS of Georgia-Federal...and get this-NOW a pre-determination AND pre-approval letter is REQUIRED!! I wonder if this is because I'm going out of network?? Doesn't matter..I'm still gonna do it! I'm so so SOOOO sick of this madness!!! Anyone else experience this obstacle?? Thank God for my faith in HIM, 'cause I'm still gonna have THIS SURGERY!!! Hadiyah — yourdivaness (posted on July 3, 2002)
July 3, 2002
Hello!!! I just don't know that I would feel comfortable going through
with a surgery "they haven't approved", what if they decide for
whatever reason to not approve your surgery. Being left holding the bag
would be devastating to me. I'd get in touch with my Insurance
Commissioners Office, www.gainsurance.org, there is a place to file a
complaint on the website. Fill it out explaining what your insurance
company has told you and that you fear they may decide not to approve after
the fact. You might also want to check out SB210 HMO's-certain
disclosures, access to out of network providers -
www2.state.ga.us/legis/1999_00/leg/fulltext/sb210_ap.htm - even though you
have a PPO, this may also apply in your situation. You could question your
insurance commissioner about this also. I may be overcautious, but I would
want to know that my butt is covered, I don't trust the insurance business
as far as I could throw it. I hope and pray everything works out for you,
you are worthy to receive the best, most wonderful life you can make for
yourself and your health. Best wishes, Jo-Dee
— tinyjo
July 3, 2002
Hadiyah, BC/BS Fed is usually one of the easiest insurances to get
approval, but they are right, they don't actually approve before hand. The
doc submits after surgery for reimbursement. Check with your surgeon on
how his office handles BC/BS Fed. I can't believe he doesn't have
experience with this one and will know what to submit and when for
approval. I have BC/BS Fed in Va and had zero problems with
approval-payment after the surgery. It may be the extra paperwork is
needed because you are out of network-just keep in mind that you will pay
more out of network. Can you find a surgeon in network? One thing I do
not like about BC/BS is that they will pay 80% of out of network costs, but
those costs are what BC/BS has arranged with in-network docs, which is
hugely reduced from the actual cost, so many out of network docs expect you
to make up the difference. Check this out.
— Cindy R.
July 3, 2002
Federal Blue Cross quit doing pre-determinations for WLS a couple of years
ago. But, if your BMI is over 40 and if you are over the age of 18 -- then
the surgery is a covered procedure -- no diet history, no co-morbidities,
no letter of necessity from you PCP required. I went through the same
things your going through when I had my surgery 10 months ago. I will say
that BC of Alabama which manages my plan did not have their system set up
to deal with the WLS claims -- the system automatically denied the surgery
because of the morbid obesity diagnosis code. I did have to call several
times and the customer service rep had to manually override the system and
resubmit the claims. Everything was covered eventually though! I have not
heard of people in other states having this problem, but everyone in AL
with Federal BC has had similar problems. Your out of pocket expenses will
be greater though since you are going out of network. I used a BC PPO
physician and hospital and my out of pocket expenses were between $500 and
$1000.
— Denise C.
July 5, 2002
In 2002, Blue Cross split changed the options from high and standard to
standard and basic. I had WLS surgery last year under standard--it took a
while to get the codes right, but it was taken care of. Now, as I
understand the plans, standard option covers WLS while basic option does
not. If you have standard, you should be covered.
— Mary N.
June 18, 2003
Original Poster Here: I just want to say “Thank You”
to ALL of you, for taking the time to respond to my question(s).
Oftentimes, I’m so busy reading and responding to others, that
I’m unable to get back to my own posts. I try to make time for
others just as others have taken time for me both pre and post-operatively.
You clicked on and shared your knowledge, when you could have simply moved
on to the next question(s) from others. I appreciate you! LAP RNY 9/3/02
265/158/115-126 and currently on a plateau...Luv, Prayers and {{{HUGS}}}
Hadiyah McCutcheon, a.k.a.~~
— yourdivaness
Click Here to Return