Ok, I have never had so many problems understanding an insurance companies break down of pay in my life. In FL with United Health it was clear cut and understood and no problems. I thought I had a handle on how BCBS did things but now I sit here looking at my hospital bill and it is a few hundred higher than I expected and what the hospital told me should be my final bill after calling insurance before surgery. If someone can help me out in understanding where my thinking is wrong I would greatly appreciate it.

My Maximum out of pocket according to the insurance company between Insurance and Co-Insurance is $1250.00.

My Insurance Deductable is $250.00/per family member (this only had 23.00 left to meet it when I paid my surgeons fee, then the co-insurance kicked in and I had to pay 10% of whatever the $3000 fee that was left which was $300.00 which I was told would go towards my co-insurance deductable and it did)

My Co-insurance deductable is $1,000.00/per family member (or no more than $2000.00 for the whole family). So the surgeons fee that I paid the rest of is supposed to go towards the thousand, now making the deductable I have left to cover before I have met my maximum out of pocket $700.00)

Now in this time between scheduling my surgery and having my surgery I have also been to my GP and had the battery of tests that my surgeon required before hand done, which I have recieved and paid bills for and in benefit explination notices from BCBS was told some of this also went towards my deductable making it even less to finish having to pay (totals about $75.00 more paid towardds co-insurance deductable.)

Now this is where I get confused on the situation. I bill from the hospital was $900.00, don't get me wrong I know that compared to what others have had to pay or are paying that this is great, however it is not what I expected nor what I was told to expect. According to what I was lead to believe is that once co-insurance kicks in I am required to pay 10% of my bills UNTIL I HAVE MET MY MAXIMUM OUT OF POCKET, which even though my math isn't fantastic (I am just doing the co-insurance here because reg. insurance deductable has been met) $1,000.00 - 300.00 - 75.00 = $625.00 of a deductable left to pay, so even though my 10% of my hospital stay is $900.00, shouldn't I only have to pay the $625.00 left to cover my deductable which would then have met my max out of pocket making everything else covered 100%? And on top of it I was just told by insurance that yes max out of pocket was met on both ends of insurance and co-insurance the dates of surgery and days of stay but my er visit 7 days later for what they thought was a blood clot is going to cost me $117.00.

So if someone can please explain where my thinking is wrong I would greatly appreciate it.

Does anyone know how they are? I was assigned a nurse through them. We have already spoken. I was told i do NOT have to do a consecutive 6 months of supervised diet as long as i have had 6 visits within the last 2 years and i have. I've been following my physician and nutritionist for well over a year now and had that faxed to her. She said she approval process is relatively easy. My bmi is current 52 and i have ashtma, feet problems, sleep apnea, pre-diabetes, back pain, problems with absesses boils yuck due to rubbing skin, etc. She said i met all the criteria. My program requires sleep studies which i had already and at least 2 months of cpap therapy which i have also already completed. The process for my surgeons office is 4-6 months and my new deductible doesn't start until April 2013 =) i found this out yesterday. Also i have $5500 oop so far and UHC told me under my ppo plan once i hit the $7500 max oop they will cover 100% which means i won't have to pay my co-insurance granted surgery is before April 2013. At this rate with all i have done already as part of the requirements i may just make it.

And my center is a center of excellence as well as the surgeons and my company doesn't exclude WLS so how quickly do you all think i would be looking at for an approval? My bmi has been over 50 now for over 5 years and my sleep apnea was just diagnosed in July. I also had my gallbladder out last May,

Within the 12 months prior to the time of surgery, the member must meet all of the following requirements:

1. Documentation of previous participation in conservative (non-surgical) weight loss program or diet program/plan (e.g., Weigh****cher, Jenny Craig).

This is the only part that trips me up.  I called the insurance company (for whatever that was worth) and all she would do to me is read the policy.  The same one I've read a million times!!  "All I can tell you is what the poicy says"....  Yep, heard that a dozen times. :)  Well, my information will be sent in hopefully this week. After that, i just wait. 

Does anyone know their requierements for surgery approval??

Hello,

I have Aetna PPO and myself and all three of my kids were approved for surgery.  Yes, there are hoops to go through but not much different than any other insurance.  If you go to Aetna.com and in their search engine type in 0157 it will bring up their clinical bulletin of the reqirements needed to qualify for bariatric surgery. 

Basically, you need to do a 6 month physician supervised diet or a 3 month multidisciplinary program (one or the other).  Three of us did the 3 mo MD program and my one sone did the 6 month plan.  YOu have to prove being morbidly obese for the past 2 years (meaning a BMI of .40 with no co-morbidies, or a BMI of >35 with at least 2 documented co-morbidies)

If you meet the requirements and are going to pursue, let me know and i can send you some stuff on how to go about doint the 3 month program as I have shared it with others on this site.  Like I said, myself and all three of my kids have had surgery.  Two of us were denied at first and I needed to appeal, but won the appeal so I have a lot of experience and knowledge of what type of documentation is needed for approval by Aetna.

Hope this helps.

Nan