Question:
Told I Must Have Surgery Then Submit, Has BCBS Ever Told Anyone Else This?

I called the insurance company a few days ago, and I asked if they covered the lap RNY procedure and the lady was very vague and then said "its not covered", then she proceeds to tell me I would have to have the surgery and THEN submit it to them, and if they denied it I can resend it...I am lost here...and can't afford to gamble with them denying me in the end...can anyone enlighten me here as I am insurance illiterate! ? Thanks soo much guys!    — doit 2. (posted on January 12, 2003)

January 11, 2003
Hi Jean, I am now 4 weeks post op and I also switched insurance companies to have the RNY done. I am a bcbs participant, but my doctors office took care of getting approval from the insurance company. My BMI was 60 and I had other morbidity factors to help prove the case. Doesn't your doctors office handle the insurance approval? I live in MI, so I don't know if BCBS is the same all over. We have traditional. Good Luck!
   — Laurie B.

January 11, 2003
I have bcbs federal employee program and they told me the same thing. I called them to make sure they understood my whole scenario and they told me that they no longer have a pre approval dept. Now my surgeon's staff is hesitant to schedule me for fear of nonpayment by the insurance. I asked my PCP to call the surgeon's office and help me. Make sure that you don't have the bcbs that excludes gastric bypass surgery. Otherwise I understand they should pay if you meet medical necessity. Good Luck, We are in the same boat.
   — Giovanna F.

January 11, 2003
Hi, I, too have FEP BCBS and had surgery on 12/5/02. I was right at the 100 lb over ideal and a BMI of 41. My insurance stated gastric bypass was a covered benefit and they don't pre-approve. They gave my pre-cert to the hospital and that was it. I was worried because I didn't have any real serious co-morbidities (i.e. astham, sleep apnea, diabetes) but I took heart medication for an elevated heart rate (problem with electrical impulse in my heart) and I had knee surgery a couple of years ago...aches, pains, and that's about it. I'm 35. I had a lot of problems with the hospital and they wanted me to pay upfront - my doctor was an angel and helped me get this waived. Have your insurance send you (if you don't already have it) the information where it states your surgery is a covered benefit. The hospital submitted their claim on 12/15/02 and they were paid on 1/2/02. Good luck.
   — Debra L. H.

January 11, 2003
The previous poster was right about BCBS FEP (federal employee plan), but BCBS calls their pre-cert dept the UM or UR dept (utilization management or review). Please remember when you are calling the insurance company you are talking with a customer service rep. They are limited on what they know and only have a basic working knowledge of insurance. If they put you on hold they are usually asking someone else for the answer-and it's usually not the supervisor. Depending on your plan, again there might not be a pre-auth or pre-certification. Ask to be transfered to the UR or UM dept and ask them. Make sure you get their name and ext. They will be able to give you a definate answer.
   — Robin J.

January 11, 2003
I, too, had the same problem with BC/BS Federal. My BMI was 40 and I was just (to the pound) 100lbs over. I also had GERD and a family history of hypertension, etc.., I took the chance without a pre-aproval, but my surgeon wouldn't do a DS or RNY over 100cm because he said that BC/BS considers it experimental. Luckily, they paid 6 weeks after surgery, with no problems whatsoever (the total billed amount for the surgery was 30k!)
   — jengrz

January 12, 2003
I also have federal bc/bs. I was not borderline..well over the qualifications with a BMI of 50 and 150 lbs. overweight, but I had absolutely no problems getting them to pay. They did only cover 90% so I paid about $800 out of pocket for my 10 percent of surgeons fees, anesthetist, $100 hospital copay, labs, etc. and my initial consult with the surgeon that was not covered. But I was in the hospital for 10 days (5 in ICU) with a leak and second surgery, and that was all covered under the $100 hospital deductible. I have yet to hear anyone not being covered by Federal BC for the surgery. Personally, I was thankful not to have to go through the long preapproval process I hear so many others go through..It was only two weeks between my inital consult and surgery date.
   — sheltie

January 12, 2003
I also have federal bc/bs. I was not borderline..well over the qualifications with a BMI of 50 and 150 lbs. overweight, but I had absolutely no problems getting them to pay. They did only cover 90% so I paid about $800 out of pocket for my 10 percent of surgeons fees, anesthetist, $100 hospital copay, labs, etc. and my initial consult with the surgeon that was not covered. But I was in the hospital for 10 days (5 in ICU) with a leak and second surgery, and that was all covered under the $100 hospital deductible. I have yet to hear anyone not being covered by Federal BC for the surgery. Personally, I was thankful not to have to go through the long preapproval process I hear so many others go through..It was only two weeks between my inital consult and surgery date.
   — sheltie

January 12, 2003
i had bc/bs of calif and had to have precertification prior to surgery..this dosnt always guarantee payment but its better to have then to not have. personally i have never heard of a insurance company telling someone to have something done then submit for autherization or payment. I would get the approval first just my opinion...also sounds like u ended up getting an inexperienced rep, try speaking to someone else....good luck
   — Deanna Wise

January 12, 2003
It seems a lot of people have been asking about precert/preapproval and what BC/BS will pay for. All BC/BS plans are different and it is important to read your plan book and see what they do cover and whether you need pre-authorization. I have federal bc/bs (Wash., DC metro area) and per my book they will cover _gastric bypass or gastric stapling_ if the person is 100 pounds overweight. No comorbids were necessary and no pre-approval for the surgery. I did have to be precertified for the hospital stay and basically if they precertify you for your hospital stay then how can they come back later and deny paying for the WLS when that is the reason for the hospital stay? I would read my plan brochure and then take it in and have the doctor read it. Although if they take that insurance they should be familiar with how that insurance plan works. As long as you follow the criteria in the plan brochure there should not be any problems.
   — Lisa N M.

January 12, 2003
It seems a lot of people have been asking about precert/preapproval and what BC/BS will pay for. All BC/BS plans are different and it is important to read your plan book and see what they do cover and whether you need pre-authorization. I have federal bc/bs (Wash., DC metro area) and per my book they will cover _gastric bypass or gastric stapling_ if the person is 100 pounds overweight. No comorbids were necessary and no pre-approval for the surgery. I did have to be precertified for the hospital stay and basically if they precertify you for your hospital stay then how can they come back later and deny paying for the WLS when that is the reason for the hospital stay? I would read my plan brochure and then take it in and have the doctor read it. Although if they take that insurance they should be familiar with how that insurance plan works. As long as you follow the criteria in the plan brochure there should not be any problems.
   — Lisa N M.

January 12, 2003
Lisa N Maryland is correct when she says to check with the surgeons office. They are used to submitting the insurance paperwork and would know if your insurance was going to pose any problems. I, too, have the BCBS Federal and was told no pre-approval, but my doctors office had worked with them before and assured me that they are one of the easiest to work with. They were! BCBS plans are different though, so check the policy carefully. Some of them deny WLS as a matter of policy, however, will approve if "medically necessary", and usually we meet that criteria.
   — Cindy R.

January 12, 2003
I have bcbs federal employee program as everyone else that has posted. I called and they said as long as it is "medically necessary" it will be paid. My BMI is 42.1 so im covered. BUT seeing what everyone else has had to say makes me feel better anyway. Without them actually "pre-approving" it is scarey. I do wonder how much out of pocket I will spend. I live in Maine and the cost of living is lower then in many states, so I am thinking I shouldn't have to pay more then $2000 complete. If anyone thinks I am off on the amount, please let me know. [email protected] Thanks :)
   — TheresaC

January 13, 2003
Get the approval first!!!! There are some procedures that need prior approval, if you wait until after you do it it's too late. Good luck:)!!!
   — Kimmie C.

January 13, 2003
I also had BCBS and they told me that I would have to have the surgery and then they would decide. Just the other day someone wrote in and said that they assumed it would be paid afterwards. They are on their 3rd appeal with no luck. Be careful get the approval in writing. I switched to another insurance company because of that, my doctor said that I would have to pay up front and get reimbursed from the insurance company. I can't afford to do that.
   — C. Zibrowski

January 13, 2003
I also had BCBS and they told me that I would have to have the surgery and then they would decide. Just the other day someone wrote in and said that they assumed it would be paid afterwards. They are on their 3rd appeal with no luck. Be careful get the approval in writing. I switched to another insurance company because of that, my doctor said that I would have to pay up front and get reimbursed from the insurance company. I can't afford to do that.
   — C. Zibrowski

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