insurance question

 

I have HMO BC/BS OF MASSACHUSETT FOR insurance. there are no Massachusett nor in network revision doctors.  I want to see Dr. Roslin in New YorkI have HMO BC/BS OF MASSACHUSETT FOR insurance. there are no Massachusett nor in network revision doctors.  I want to see Dr. Roslin in New York, but he is out of network per my insurance. so i am in the process of getting a referral from my pcp to see Dr. Roslin, however it is totally up to BC/BS. Of course i am waiting for a response from them.  But does anyone knows the process with insurance when this type of thing happens,(revision done only by out of network doctor) will the insurance approve it if there are no in network drs?

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You will need to review the exact details of your policy regarding revisions. Some policies provide generous coverage, at the other extreme, some have "one wls per lifetime" policies. You may have to meet certain criteria. If you meet their criteria, you will probably need to justify why DS rather than some other kind of revision.
     You may find yourself getting denials and needing to do appeals. Every insurer has some kind of internal appeals process, and most, if not all states, have an external appeals process available also. But there are so many different policies out there that you really need to read your policy for yourself. Don't trust what someone tells you over the phone, read it yourself.

Larra

 Larra
Thank you 

thank you for this knowledgeable information

I had BCBS/TN Medicare and while they approved the DS, I was on my THIRD appeal for the doctor...he was not IN state. So I called EVERY bariatric surgeon IN state on their list and asked if they would do the DS on a lightweight...Most did not even do the DS, the ones who did were either NOT on BCBS or NOT in a COE (another hoop I had) or did NOT work on lightweights...

I had a detailed list of every office, who I spoke with, what time and day and their respoinse...when I found ONE surgeon who was in state, in network and willing to do the DS on a lightweight...AND had done others here.

You have to be prepared to work for this and Larra is right...it may take several appeals but do not give up. Make sure you have medical reasons for the DS...mine was two fold, the need for NSAIDS (I was already on celebrex and had been for over 10 years) and the best results for resolving diabetes.

Good luck and if you need help, you will find the most knowledgable vets elsewhere...google weight loss surgery and proboards.

Liz

 thank you again, this is great info