Question:
Insurance won't pre-certify the procedure. Bc Bs Fed Emp Program
Any one deal with BC BS FEP? They deemed the procedure medically necessary but won't precertify it. This means they will consider payment after the procedure is done! I was told that if they deem it medically necessary, they usually pay for it. I am considering taking the risk and hoping for the best. Has anyone gone through this and what was your outcome. HELP! Rhonda — R H. (posted on October 11, 2000)
October 12, 2000
Rhonda - I have BC/BS FEP also and they told me the same thing. I asked
what criteria was used to determine if the procedure was medically
necessary. They advised that obesity was the only criteria required. If
that is the case, then I should certainly have no problem <g>. It
does sound too easy though, I guess I'll just wait and see what happens.
If my surgeon will agree to it, I plan to go ahead with the surgery. If
BC/BS will not pay I will fight them with everything I have at my disposal.
I choose my battles carefully, but this one is too important not to fight.
Let me know if you find out anything new and I will do the same. Best of
luck to you. Lynn T.
— Lynn T.
October 12, 2000
YES!! I had the same problem!! The only way that I could get my doc to
schedule my
surgery was for BC/BS Fed Employees Program to send him a copy of their WLS
Criteria ...
Based on what they faxed to him he determined that the procedure would be
covered and scheduled
my surgery!! A week or so after that I got a letter in the mail from BC/BS
stating that my
"Admission" had been authorized ... They will pre-cert the
admission for the surgery but
they wont pre-cert the surgery any more ... Doesn't make a lot of sense to
me ... but
thats the way the policy current reads ... Have BC/BS send your doc a copy
of their criteria
for WLS ... if you meet it, there wont be a problem with them paying for
it. Hope this
helps!!
— Donna H.
October 17, 2000
Gloriosky!!! I'm having the same problem. I also have the BCBS Federal
Employee Program. BCBS says they do not give a "Predetermination of
Benefits" anymore, but have precertified my admission. They say they
will determine payment after the claim is made (i.e., after surgery is
performed). Gastric bypass surgery is listed as a benefit and I have
several co-morbidities (diabetes, hypertension, degenerative disk disease,
arthritic knees, hips, etc.)so I'm 90% sure I'll be approved. Now I just
have to convince my surgeon's office so I can get a surgery date. Wish me
luck and say a little prayer for me, please! I am 48 years old, 5'2",
and weigh 330 lbs.
— Dottie K.
May 22, 2001
I have BCBS-FEP as a retiree and am wondering if Medicare will pick up the
hospital portion as with any other hospitalization. Anyone have any
experience with this?
— [Anonymous]
August 15, 2001
If it makes anyone feel better, a lady my husband works with just had it
done and they paid. My MD says it is almost always covered. I'm going for
it. Good Luck everyone.
— [Anonymous]
February 11, 2002
I am having a real hard time with Federal BCBS.
They have denied by surgeon's and his assistant's
claims and only paid about $6,000 on the hospital
bill of $61,000. They say they need medical records
I have asked these be sent. It's frustrating because
I am ultimately responsible for these bills, but have
no control over what is documented in my medical records,
nor whether or not the surgeon's office or the pcp's
office send them. Neither do I have any control over
whether BCBS loses them or denies receiving them. None
of this is in my control but I am responsible for the
bills. I don't know if I will ever get this mess
straightened out or not. I am wore out with it. I have
written BCBS of long letter explaining my many comorbidies
and suppling what records I had. I haven't heard a word
from them. I hate BCBS and will be glad when I can change.
I wouldn't have this insurance again if my employer gave it
away free. Curstomer Service people talk but have no authority to do
anything.
— N M.
February 11, 2002
Wow, Nancy, that stinks! I have never heard of anyone with BCBS-FEP having
a hard time getting them to pay, I certainly didn't. If you meet the
criteria, I don;t see how they can deny you. You need a case advocate or
somehting, you may want to contact your union rep if you have one, your
benefits office, or your state insurance commission. I am pretty sure you
will NOT be stuck with this bill. You need an advocate in your doc's
office too, have they dealt with BCBS befre, adn with theses same problems?
— blank first name B.
February 11, 2002
Wow, Nancy, that stinks! I have never heard of anyone with BCBS-FEP having
a hard time getting them to pay, I certainly didn't. If you meet the
criteria, I don;t see how they can deny you. You need a case advocate or
somehting, you may want to contact your union rep if you have one, your
benefits office, or your state insurance commission. I am pretty sure you
will NOT be stuck with this bill. You need an advocate in your doc's
office too, have they dealt with BCBS befre, adn with theses same problems?
— M. A. B.
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