BCBS of Michigan

gafrost
on 5/11/07 6:42 am - Freeland, MI

I have this checklist from my group advisor, and I was wondering if someone could help me decipher this list a little better, I don't want to start looking for a surgeon until this September, Pretty sure I already know where I'll be trying to go, but I'm not quite sure where to go from here, I started on my journey a few years ago, but insurances changed and then so did criteria, so now I'm basically starting over. All of the following criteria must be met:

1) must weigh at least 250 pounds or be 100 or more pounds over weight OKAY UNDERSTAND THIS ONE

2) must be between ages 18-60 YEP

3) past medical history must reveal inability to regulate weight conventionally THAT WOULD INCLUDE WHAT, I HONESTLY DONT THINK MY LAST DOC WILL RELEASE MY MEDICAL RECORDS BECAUSE OF NON-PAYMENT, (WE WONT GO THERE) DOES HE HAVE TO RELEASE THEM TO MY CURRENT DOCTOR?

4) doctor must document failure of non surgical management for minimum of 12 consecutive months in last 4 years before gastric surgery was recommended. CONSECUTIVE MEANING? DO THEY MEAN FROM 1/1/07 TO 1/1/08 I FAILED TO LOOSE WEIGHT WHILE SEEING THIS PARTICULAR DR?

5) documentation must include:

- periodic weight checks DOES THIS MEAN WHAT? THEY ARE SO VAGUE, I HAVE BEEN GOING TO A DR SINCE SEPT. OF LAST YEAR, NOT EVERY SINGLE MONTH, BUT I WOULD SAY EVERY OTHER MONTH, WILL THIS DO?

- dietary therapy WHAT THE HECK IS THIS?

- physical exercise OK, DOES THE DOC NEED TO COME WATCH ME WALK AT HOME, COME ON HOW IS THIS GOING TO BE DOCUMENTED?

- any behavior therapy or counseling AGAIN, WHAT THE HECK IS THIS?

6) evaluation performed by physician to show patient is emotionally stable GO SEE A HEAD DR. OK, DONE THIS BEFORE.

7) any additional details to support necessity CO-MORBIDITIES

8) charges are subject to deductible and coinsurance

9) claim is subject to past payment audit Any help or advise at all would be greatly appreciated. thanks, Amy

Just_Mel
on 5/11/07 8:57 am, edited 5/11/07 8:59 am - TX

RNY on 06/04/07

I'm fairly certain that the Dr has to give you a copy of your medical records, they are YOUR records. They can charge a fee though. And I'm not sure of what the allowable fee is. I know one of my Dr's would fax the records to another physician for free, but would've charged 25$ for me to get a copy. The consecutive months.... 12 months in a row. Not a month or two here and a few months here. Must be 12 in a row... so yeah, basically Jan-Jan or however you went. Basically they want to know that a Dr was monitoring your blood pressure, temp, diet, exercise and weight loss/gain for atleast one year. The periodic weight checks... well since they don't specify that it be every month, every other month would probably do... but if you weren't seeing the dr every month, then the 12 consecutive months MIGHT be out the window. Dietary therapy... they want to know if the dr had you on a specific diet(s). Or maybe if you saw a dietician. If you were seeing a dr for your weight, they probably have that documented. The exercise... again, if you were seeing a dr about your weight, most likely they asked about your exercise habits and made documentation of such. Behavior therapy or counseling.... They want to know if you saw a counselor about food. Possibly even a dietician or nutritionist. The doctor may even work for this..... if he was talking to you about your problems with weight/food/exercise. The best thing to do is give it to your doctor and let him make as many interpretations as he/she can. When and if they think they've fufilled all the requirements, they'll submit to the insurance... if it wasn't enough, then the insurance company will deny and give them the reasons (ie: what was lacking). I haven't had surgery yet, I haven't even had mine submitted to insurance yet..... but this is what I was told by both my insurance company and my doctor's office. Hope it helped you some. GOOD LUCK!!!

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