Question:
Has anyone run into Federal BC, not precertifing?
I am trying to get approval for breast reductation, that is medically necessary, for reliev of neck pain. BC, said they will not decide until after the surgery if they will cover it or not. Any help or insight would be wonderful. Thanks Barbara — barbara M. (posted on October 31, 2003)
October 31, 2003
Yes, I have BC/BS Federal and yes they don't pre-approve. However, I have
never had any problems with them not paying for any surgery, visit, or
anything else once it was done. In getting approval for my WLS they said
they didn't pre-certify/pre-approve but I did get a letter for them that
said "this is a confirmation of medical necessity under the Federal
Employee Health Benefit Program". I don't know why it's like that,
but it just change this year.
— Candace V.
October 31, 2003
I have BC/BS Federal and am trying to get approval for panniculectomy right
now. I am fighting for approval and found out from a very nice lady that
BC/BS will NOT approve any OUTPATIENT procedure. A lot of the
reconstructive procedures are coded as outpatient, even though they usually
require a hospital stay! Anyway, BC/BS has been instructed by our FED
providers not to authorize any outpatient procedure. If they receive this
code they will automatically say "no authorization". Now, I
don't know if they would end up paying or not. That is when it gets risky.
They may or may not pay! This sounds like really bad business practice to
me, but what do I know about insurance companies and how they operate? We
are all just sitting ducks hoping they will pay. Unfair and should be
illegal! If a procedure requires an inpatient stay, they may review it. I
am considering switching to another FED insurance during open season.
BC/BS is really becoming a pain to deal with. They take our money (more
each year), then deny necessary procedures. You can tell I am po'd at
them! Good luck.
— Mylou52
November 1, 2003
I have Bc/Bs Fed PPO and ran into that with my wls. I asked them and my
surgeons office about it and what they both said was that the surgeons
office calls them, insurance company asks them a list of questions. They
then say if everything is the same on the day of surgery as it is today it
will be paid. I have only heard of one person that was not compensated
after surgery and that was because her BMI had dropped from like a 42 to a
38.
I also have never had a problem getting Bc/Bs to pay for any surgeries
myself or other families have had to have.
Good luck!
— TheresaC
November 1, 2003
I had BCBS/PPO and they also didnt 'precertify' BUT that does NOT mean you
can not ask for a 'pre determination'!
which basically they 'review' and determine if its covered under your
policy... If your worried, I would get a pre determination at least; then
if for some off chance they try to deny later, you will have that pre
determination for your records.,., etc.
— star .
November 1, 2003
Hi, I have BC/BS federal and they would not precertify may RNY. But they
sent me a letter stating that they would be happy to allow me to obtain
this procedure and stated the number of nights they would allow me to stay.
I have had no problems with them paying their portion of the bills.
— Debra W.
November 2, 2003
Hi, I have BCBS FED also. They did do the pre-cert for the WLS but will
not do the pre-cert for any reconstructive surgery. I am getting tummy
tuck, thigh lift and breast augmentation. I know they will not pay for the
breast augmentation, but am hoping for the tummy tuck and thigh lift to be
covered. You basically have to have the procedures done, file the claim
and hope they pay. It is in the clinical notes submitted to the insurance
company about how much tissue was removed and what exactly was done to the
patient and why. BCBS has physicans that look over the clinical notes
submitted and decide if the procedures were medically necessary. I am
going to proceed with mine and see what happens. I am making sure to take
a whole bunch of pictures of myself pre-op for evidence of a large pannus,
flappy thighs, etc. I will have this ready to appeal if they deny
anything. It seems ridiculous to me that they would deny this after
approving my WLS. Its not unusual to think that the patient will loose a
large amount of weight after WLS and would then have excess skin and tissue
left over !! Linda LapRNY 02/11/03 -120lbs
— LindaBF
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