Shannon, Pam and other insurance experts....need help

I am 4 days pre-op and might have an insurance glitch.  Last week I received 2 letters from my insurance company (BCBS GM - PPO) regarding 2 different procedures.  Basically they both state the same thing except one is for the Lap Band and the other is Gastric Sleeve.  The later dated one is the one listing Gastric Sleeve and that is the procedure I am having. I really didn't think twice about it and since I hadn't heard from the coordinator about receiving the approval letter back they submitted I left her a message stating I had 2 things in writing - one correct & one not.  I figured I had my end covered even if they hadn't received the approval back. 1st question - Will they send an approval letter when a pre-approval isn't needed?  (I called my insurance and she said a different area handles that but they may not send one if one isn't needed.  Which is what both the letters state as long as the requirements were met.) The coordinator is calling on Monday to verify that her request for approval is indeed correct.  I think the letters I received are form letters and having been in customer service before it is easy to plug the personal info in and print it without changing the body of the form.  OOPS! Oh well, so is my thought as long as I have a correct one I'm ok. The one thing that my insurance customer service rep said was that it was covered and didn't need prior approval unless it was inpatient.  UM - ok now I am concerned.  It is too late to find out what it is coded as going in and I know I could be out within 24 hrs but it sounds like it is more realistic to be in there longer.  She didn't sound like it was a big deal and said the dr would have to call if it was going to be over 24 hrs and get approval.  Sounds simple, but does kind of worry me. And do you know from what time the BMI used?  Is it at the initial consult or time of surgery.  My surgery doesn't have any prerequisites as long as my BMI is over 50.  What if I am under 50 at the time of surgery?  I wanted to lose as much as possible before hand - to show that I am serious...but I know that on my own accord, the weight won't stay off for long without surgery. Anyway - I am not worried about the surgery only worried that I've hit a glitch.  I will put the letter on my blog so y'all can read it and tell me what you think. TIA for any light you can shed. Gwen

My understanding is that BCBS doesn't require pre-approval for the surgery.  But your surgeon's office has to make sure you meet the criteria, or they won't get paid.  So if your surgeon's office is comfortable, then you shouldn't worry either.  I also wouldn't worry about getting 2 letters.  It's not unusual for the surgeon to request approval for different types of surgery just in case you change your mind at the last minute -- they are already covered.   As for the inpatient clause ... the hospital will know all that information too.  When you're admitted, they pull your insurance criteria to see what's covered and what they need to do to make sure they get paid.  If there's a requirement for inpatient care, then they'll deal with it.  I'm not sure when your surgeon records the "official" weight.  Some use the initial consultation, some use day of surgery and some use some other appointment.  Mine used the Pre-Admissions testing weight which happened about 2.5 weeks before my surgery.   It sounds like all your insurance stuff is in order and your sugeon's office still has Monday to deal with any last minute issues.  Rest easy and enjoy this weekend ... you'll be on the losers bench very soon. Pam  

Gwen- Number one they shouldnt have even done the surgery if they didnt have the pre auth number...so I would complain to your surgeons office.  At the U of M- the docs wont even touch you unless you are approved- or if you are self paying. How much are the bills and was it a bill or a explanation of benefit letter?  BCBS PPO requires 6 months unless your BMI is over 50 but they still need to cntact your insurance company...if it is denied I would make the surgeon pay for the surgery since it was THEIR job to get you approved. Let me know how it turns out. Shannon

Shannon - There is no pre-auth needed.  Honestly, today the rep said "just how many times do you need to hear that?"  She wasn't rude....it was because they log each call and I know between the coordinator and myself there has been 6 or more calls verifying that a pre-approval is not needed.  I haven't received a bill since nothing has been done.  The reason the surgeon's office is so concerned is because they want to make sure it is all on the up and up and they don't get stuck with a bill.  And it wouldn't be on them anyway since she left it up to me and I decided (after being told no less than 4 times myself and requesting the letter) to go ahead and schedule without having a response from the request for pre-approval.   Since an approval was requested when one wasn't needed, I am not sure (and neither was the rep I spoke with today) if they'd even send an approval letter anyway...especially if they look at my account and see that both the coordinator and I have checked so many times.  Like, "why send a letter if we keep telling them" type thing. Thanks for your input!! Gwen

Gwen i offered once prior to being yourangel and letting other on the sie know how you were goig, It is a choice totally up to you, you may have a close friend, or oher indiiddual who is similar to you i time spinl, Either way, If you need soone who has ben through the system alredy,please let me know. I would be hoor to be your angel. If you hav esomeone else in mind, I certainly won be insulted, just want to make sue you are covered and taken care of, AMY h

Thanks!  I didn't respond, did I?  (I remembered someone offering and I couldn't remember who or where I'd read it.)  I'm sorry.  I'd love that.  I have actually had a couple of other people offer too...Jodie and Bernice....it is nice to have people looking after me.  I'll PM you! :D

Did I hear my name? Heh. Your surgery will be here in no time.. then you will be getting skinny. Woowoo.

Gwen, I don't know about BCBS. What I do know is that MMPC uses the weight from your visit 2 weeks pre op.  I asked the same question you had while I was standing on the scale.  They actually may even use the weight from your first visit post orientation. No worries on the BMI!! Thinking of you!!!!!!!!!!!!!!!!

Thank you!!