Question:
Which is better to approve me for WLS, BC/BS HMO or PPO?
I currently have Humana HMO and got approved for this surgery however my DH job is switching ins. co. on 1/1/02 to BC/BS and I can't get into surgery by that time. I have to pick either BC/BS HMO or PPO, does anybody know which is most likely to approve me for WLS? — blank first name B. (posted on December 13, 2001)
December 13, 2001
Hi Kimberly. I have BCBS PPO. I didn't have any problems getting approved.
Other than having to be 100pounds overweight, or having comorbidities, they
didn't require much. I did include a diet history ( they didn't ask for it,
my surgeon is the one who wanted it and he sent it in with all my paperwork
)and all they basically requested was a psych evaluation. That was it. Once
the psych eval. was done, I was approved. I don't know how the HMO
works....I don't know if you can call and ask BCBS or not. If you do, just
make sure you say "gastric bypass surgery". DO NOT say
"weightloss surgery". Weightloss surgery is considered cosmetic.
— Kim B.
December 13, 2001
Kim, I have PPO, thought about switching to HMO (actually, ading an HMO
policy from my work and KEEPING my hubs PPO) for better $$$$$ coverage.
Here is what BCBS told me: (keep in mind I am in CA.) They told me since I
already had an approval and surgery date, the HMO underwriters may not
approve it. ( This didn't make sense to me, since they are both BCBS, but
that's what they said.Something about the PPO being primary sinc I had the
date already.) The gal's advice was to stay with my PPO. Here is what I do
know. If you have PPO, you can go straight to the WLS Doc. They will help
fight for your approval. If you have an HMO, you will first have to find a
PCP that is willing to refer out for WLS, and some do, so don't. ( Just one
more obstacle.) My experience with my PPO and Doctor has been A+, my ONLY
issue is that my doc isn't in any plan, and I have to fork over $7800 up
front. OUCH. Keep in mind...an HMO has to take you with or without
preexisting conditions, whereas a PPO does not have to cover your
pre-existing conditions. What worked for me was to call both insurance
companies and ask them how it would work if I switched. They were very
nice. And again, BCBS PPO approved me really fast for WLS. I may just have
to find a doc in my network to save some money. Good luck to you, email if
you need to. Hope I didn't confuse you :)
— Michelle P.
December 13, 2001
Hi Kimberly, I am sorry that I can't answer your actual question. I wanted
to let you know that I have been following your problem over on the message
board. Isn't there some way to get in to have the surgery this month? I am
sure you have already checked, but it seems like the surgeon's staff would
bend over backward to get you in, especially since you have approval
already. Maybe a different surgeon? Best of luck to you and I feel for your
situation.
— Shelley.
December 13, 2001
I have BC/BS PPO but have had the BC/BS HMO before we got switched to PPO.
I didn't have any problems getting aproved, infact, I went to the insurence
section of this website and looked at the many faces of BC/BS... and there
are a bunch. The only thing is with an HMO, you have to have a referal, and
jump through the hoops, but I didnt see that as a problem, because I did
it that way even though we were a PPO...I was use to the HMO. GO to
www.bc/bs.com
this might help also.
Ruth
— Ruth S.
December 13, 2001
I just wanted to thank you all for your helpful answers. I greatly
appreciate the support. Thanks again.
— blank first name B.
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