BCBS PPO -JOKE!!

*"I have a friend who has month by month notes on weight loss attempts (not saying they are from her doctor, but she has them not the less). She is submitting her stuff this next week, so I am curious to see if they approve her. if they deny her, I know it's all a scam."* Michelle, I'm curious about this. Please try not to take this the wrong way.. I'm not attacking you or trying to make you feel bad.. I just want to understand. I know it's frustrating to be denied.. we have all lived in fear of the big "denial" from our insurance companies.. but how, exactly, is it a scam if they deny your friend based on the need for a doctor supervised weight loss program if she doesn't have evidence of a "DOCTOR SUPERVISED WEIGHT LOSS PROGRAM?" I just don't understand. It matters not one whit what someone else, who works for a different company and carries their insurance with BCBS gets or doesn't get. Each employer agrees to its own policy with its own exclusions and requirements. Do **you** have the 12 month, doctor supervised weight loss program your BCBS plan requires on record? Meaning, have you gone to your doctor for regular weigh-ins and followed the weight loss plan you and your doctor agreed upon for 12 months? If not, and that's what BCBS is asking you for, you're going to get denied. Weigh****chers, Jenny Craig, Atkins -- none of it counts (even if you kept great records on your own) if you didn't do regular (i.e., monthly or bi-montly or quarterly) weigh in's and check ups with your doctor. It's a pain in the behind -- no doubt -- but it's a relatively clear requirement. Am I missing something in what you've told us?? MY policy was BCBS until January 1, this year and all I needed was a Psych Eval and letter of recommendation from that meeting to get my approval. Each plan/employer is different. I can't help thinking you're setting yourself up for a big disappointment simply because you don't have what they're asking for and you don't want to provide it because you think that requirement stinks. Stef

My papers will be submitted to BCBS next week (I had my consult on Friday). While I have evidence of a 12 month supervised diet (including my PCP's letter to support it) I only saw my PCP every 2 - 3 months. I hear as of January 2005, they require monthly visits. Frankly, a denial will be OK for me - to quote my boss - "Bring it on." I'm have BCBS as a Federal worker. It's a national plan and our plan book (that essentially serves as our contract) says the surgery is covered as long as you are 100 lbs. over normal BMI. There is no mention of a diet, nor co-morbidites (which I have). The bottom line is that it is a national contract and national standards have to be applied (I'm interested what Feds in Fla will do if they have BCBS as that BCBS there no longer covers the surgery). As soon as I have the denial, the appeal runs through a Federal OPM review. Unless I am terribly mistaken, they are screwed. From what I hear, they deserve to be. Michelle - I'm sorry for your problems. Try a lawyer before you go self pay - I hear they tend to fold if it will cost them in serious legal. Start documenting every medical expense and pain incurred due to their failure to approve surgery. See if the lawyer can recover on these costs as well as get the surgery approved. The bottom line is that BCBS's actions have to be consistent with the contract you and your employer entered in with them. If not, they should be asked to pay damages. Take Care-- Harbor

Harbor, Sounds like you have a better (and different case) than the rest of us. Just keep pointing at your contract. Go get 'em. Hope we can all keep each other posted on how it's going and maybe help each other along. Illini

You know what Michelle, I am beginning to beleive you need to paint these people a picture of what you are going through. I am sending in photos of my awful diabetic effected feet, pictures of the size of my abdomen. The edema in my legs. Then I explain to them as briefly as possible what all these comorbidities do to a person and the risks involved. The problem is simple, they have never walked in your shoes, and don't have a clue what this is all about. So paint a picture. Sometime I feel like walking in there and showing how hard it is for me to bend my knees, or get off a floor. I wouldn't wish this on anyone, but I often wonder what they would do if they had to live like we do day after day. Then they'd all be approving us. Hang in there, keep after them. Remember they DO NOT WANT YOU TO FIGHT BACK. Put a bikini on and visit their office, and ask "Do you think I wanted to become this way because It feels so good". Then see if they thinks a joke. No its a curse.