Called my insurance and got a woman who didn't know much?

I have BCBSM PPO. There are 3 phone numbers on the back of my card: customer service, predetermination, and mental health/substance abuse. I called the customer service number and said "I am calling to find out the guidlines and requirements for gastric bypass surgery." The woman said "You will need your BMI, medical history, a psychological evaluation, and (some codes which went way over my head)". This sounded to me like something my surgeon would need to fax to the insurance company so I asked if she had a list of providors in their network. She said "What kind of providor do you need?" I said "A bariatric surgeon." She said "Um, I have some Gastroenterology surgeons, will that work?" At this point I was very confused. I thought that this person would give me a list of doctors who specialize in bariatric surgery. I had no clue if she was giving me the right list of people, and I got the feeling that she didn't know much of anything about what gastric bypass is. What number will I need to call and what will I need to say in order to get someone on the phone who can help me better?

It sounds like she gave you the right information to me.  I would call back and ask for that list of requirements again --- then ask for it to be sent to you in a letter so you've got it in writing.  Then use that list as your "checklist" of things to get done.  Even if you find a surgeon who will handle the insurance approval (although BCBS doesn't require formal pre-approval) .... you still want to be the person who oversees your own medical care. By having a list directly from your insurance company you can make sure everyone is doing everything right for you. As for a list of surgeons.  Yes, I believe a gastrenterologist is what you want.  However, I wouldn't rely on your insurance company to give you a list of qualified surgeons.  They are only going to give you a list of everyone who is qualified to be paid by BCBS.  They won't give you a list of surgeons based on their experience, expertise, track record, complication and mortality rate, etc..... that is something you're going to want to research on your own.  Use the feature here on OH to start creating a list of surgeons in your region and take recommendations from friend and family members who have also had the surgery... make a master list of every surgeon you want to look into within your driving distance (however far you're comfortable traveling for surgery).   Then from that list start to do some of your own research on each surgeon.  Look at their experience (over 1,000 surgeries is best), the types of surgery they perform, their complication rate, the bariatric center they're associated with and what the aftercare program is (this is an important one) and if you're so inclined... even dig deeper to find out if there are any pending malpractice lawsuits against them.  My understanding is that almost every doctor in Michigan accepts BCBS - so that's not going to be a big deal, but it'll be something you need to verify.  You also need to determine if you're more comfortable with a surgeon who only does bariatric surgeries or if you want someone with general surgical experience and is still practicing other forms of surgery.  For instance, my surgeon of choice is also a trauma surgeon -- so I felt comfortable knowing that if anything went wrong in the operating room he'd be experienced and comfortable in more than just bariatrics and could deal with whatever happened.  You need to find a doctor who you trust and know you're feel comfortable with.  And the only way to do that is to do your own research on them. Good luck Pam

Where I work (and where I am a patient) our Bariatric Surgeons are General Surgeons, not Gastroenterologists.  However, not all General Surgeons do Bariatric Surgery...it's a sub-speciality.    She was probably asking for the ICD9 or CPT code (billing terms) for gastric bypass.  It's like the card catalog number in a library...it identifies which procedure you are having.  That is the code the dr will use to bill your ins.  BCBS also has a website that lists their providers by speciality (www.bsbsm.com).  You can sign up there for access using your member ID number. They no longer require prior authorization for bariatric surgery. As long as you meet the guidelines required (as determined by a surgeon) you qualify.   Good luck.

1.  BCBS of Michigan does not require pre authorization.  They have a certain critera which you need to meet in order to be considered for bariatric surgery.  If you meet that critera, and your physician can prove it, you do not need a pre-authoriazation.  That critera is a) BMI over 40 or if not over 40, you must be at least 35 and have co-morbid conditions.  b) you must have written verification of trying to lose weight.  This information must be documented - preferrably by your physician.  You should have met regularly with your family doctor for the sole purpose of trying to lose weight.  It can also be through Weigh****chers.  This 6 months is waived if you have a BMI of over 50.  C)  Your family physician and yourself must have a clear documented conversation of the surgery, the lifestyle changes following surgery and the care you will need following surgery. d) a psychiatric evaluation.   2.  You will need to find a surgeon in your area that performs this surgery.  You will want to find out if they participate with thier local PPO.  If they do, then BCBSM treats them as a PPO doctor.  Since the customer service rep you spoke with is with BCBSM, she probably does not have a list of bariatric surgeons in your area.   Additionally, no customer service rep from any company can recommend a surgeon to you.  They can tell you a list of participating providers, but cannot or should not direct you to any particular one. 3.  The customer service rep was asking you for procedure codes.  Each surgery that is performed, be it a RNY, a hysterectomy, even having a mole removed has a 5 digit procedure code.  The code you are going to be looking for is a 5 digit number that begins with a 45.  You would get this information from the surgeon.   The customer service rep gave you the information you requested, however, you guys were talking in two different languages.    I would call back and ask 1.  Is bariatric surgery covered.  If they say yes, 2.  ask if they can mail you the clinical (or medical) critera for bariatric surgery.   Next, I would see if your family doctor has a someone they can recommend to you for the surgery.  Contact them and find out about getting in there for a consult.  A lot of times the surgeon will have all the other information you need - that procedure code.   Hope this information helps.  

 

Hey there, you are getting some great advice here. Sorry I didn't get back to your message as soon as I would have liked.  The numbers or codes they are talking about are procedure codes or CPT codes, as someone said.  For roux-en-y procedure, the code for this operative procedure is: CPT 43644.  For lap banding, CPT 43770. For duodenal switch, it is CPT 43845.  The  ICD-9 code for the diagnosis of morbid obesity is 278.01. With your BMI and that diagnosis, that should give them enough information to tell you if the procedures you want will be covered. As far as surgeons, I would look on this site or some other site for recommended bariatric surgeons.. then call their office and find out if they take your insurance. You could probably also ask your own doctor's office for a referral or recommendation if you trust them as well.   Good luck with that, and if you have more questions, please do message me again as well. Sorry for the delay. Jodie