I guess I waited too long!!

For sometime now I have been going back and forth on whether to have WLS surgery mainly because of personal issues that has happened to a family member! Just when I thought I made my decision something would come up and I would change my mind. I finally made my final decision a few weeks ago... submitted my paperwork and tried to get the ball rolling. I was told from Dr Champions office that I would need a Phys evaluation and Nutritional evaluation before it could be submitted to the insurance company. Although their office offeres these services they are somewhat swamped so I decided to try and go out on my own to try and get this done so it wouldnt hold things up. I finally found a phys that would get me in and said that they had done the clearance letters before but they required I call the insurance co prior to my visit and verify coverage. I called the ins company and while I had them on the phone I wanted to find out the current status of coverage for WLS. I was told that they no longer make any exceptions for Gastric Bypass. I am so disappointed!!!! I told my husband I just wanted to cry!! I guess the best thing to do is wait till Dr Champions ins coordinator calls me and see what they have to say.. Im hoping that she knows something that I dont or that she knows a way around this!! Keep me in your thoughts and prayers! Thanks for your support and listening to me rant!! Ginger

My Ins company is BCBS PPO of GA. I had heard that they were stopping coverage by the 1st of the year but according to the person I talked to this am they have never supported the surgery except under certain cir****tances and NOW UNDER NO Cir****tances will cover it. OH WELL !!! Ginger LLoyd

I'd wait til Champion's office sends the package in and see what they say. Don't they have to give a dead line for stopping coverage? Good Luck gal! Tonya

Thanks Tonya for your words of wisdom!! I can only hope that you are right! I am keeping my chin up but it is hard!!!! Ginger

Send a complaint to the insurance commissioners office for the State of Georgia. They have a wonderful website and you can do everything right there. You are right Dr. Champions office is swamped and they will only go so far with insurance. For both my son and I we had to pick up the pace and do a lot of insurance work and complaints on our own. If I had relied only on the office staff I would not have been approved. My son was not approved and Dr. Champions office gave up on the file - but you know how mothers can be. I complained so much everywhere that someone finally approved my case. If you want the surgery that is what you may have to do. Best wishes - Lisa

Ginger: If they come back and say they won't cover it..STAY ON THEM!..I have BCBS of Ga and the same thing happened to me. They told me that they did not cover the process, I fought it and had my husbands employer fought for me to have it. They were more than willing to pay when they saw that I was going to fight it and that I had my husband's employer on my side as well. Another thing I did was write a letter to the Insurance commissioner stating my case and the need for this surgery through my insurance provider...that helped to push things along as well!! Hang in there and my best advice is don't give up..If they close a door find a window! Valerie

Thanks Valerie! I will stay on them and see what happens. I appreciate your support... it really means alot to hear there are people going thru the same frustrations. It makes it alittle more bearable! But still ..... gggrrrrrrrrrrr Ginger

Ginger, We ALL know that BCBS has paid multiple times this year. There are certain regulatory requirements and notifications that insurance carriers have to make to their customers if they are going to modify or limit their coverage. I suggest you contact the insurance commissioner's office. Also, I would let BCBS of Ga KNOW that you are going have contacted the insurance commissioner. NO insurance company wants to have a red flag go up on them at the commissioner's office. Here is the info... Website: gainsurance.org (put www. in front of the address) Address: 2 Martin Luther King, Jr. Drive Suite 704, West Tower Atlanta, Georgia 30334 Phone: (404) 656-2070 Fax404) 657-8542 Email: [email protected]

Thanks Tammi and Lisa for your suggestion about the insurance commissioner's office. I will give that a whirl! Ginger

Ginger - You need to check your certificate of coverage to see if the wls is excluded or not. You can get a copy from your employer. BCBS of GA will be covering the surgery next year and in fact they are putting into place a whole new wellness type of program that encompasses all of the services that wls patients need like nutritional counseling, physiologist, and mental health counseling. I have chronic asthma and bcbs has assigned a physicians assistant to monitor my asthma and help me and my doctors keep it under control. He told me that they had a big meeting last month and announced that they were very pleased with the results of wls for their patients here in Georgia and as a result, they would be improving the wls program. However, if your policy has a special clause that specifically prohibits wls, then you may have to wait until open enrollment comes around again and pick a plan that doesn't or bring it to your employer's attention and see if they can get that changed when they negotiate a new contract. In the meantime, pull your certificate of coverage and read it for yourself. BCBS tried to deny my wls by stating that my policy specifically excluded the surgery when in fact not only did it not exclude the surgery but specifically said it was covered if I had the rny. I had to get my employer involved, but once they stepped in, my surgery was approved in 48 hours! Good Luck! Lisa Baker Christopher Hart, MD 08/10/04 270/225/130 Since surgery: No more blood pressure medicine, acid reflux disease is gone, asthma is under control and I feel so good!