BC/BS PPO (NJ Plus) the Evil Empire

There's been a few posts asking about experiences with NJ BC/BS... Here's mine... they are the evil empire... they have all the power and control.. and we must beg for what we need. I have the policy issued to state employees... very comprehensive... includes WLS. In 2004, I met with a surgeon in network, completed all the pre-op testing, sleep studies, cardiac stress, etc, etc, etc. All covered. Met all the surgeons requirements, classes, meetings with dieticians, psych eval, etc. Got a date. Medical office staff sends in for pre-authorization. They turned me down for a Duodenal Switch. (I have an extrememly high BMI, and research shows this is the best type for me). OK, work the appeals process, lose twice, hire a lawyer specializing in obesity cases, 2005 go to the Pension Board for state employees where you can file the next level appeal, the BC/BS rep lied and stated that the DS was not approved for Medicare and Medicaid patients in NJ, which blows my premise that it's available for indigent and elderly NJ'ians, why not state workers? Lose.... file with the Office of Administrative Law for final level appeal, have NJ BC/BS cancel two different dates the day before the hearings. Finally, in Sept, get a notice they changed their policy to include the DS because "now it's not investigational". These (fill in your own cuss word) have made me put parts of my life on hold for over 2 years fighting them....... Thank goodness my job and 'real' life keeps me too busy to plot against the 'evil empire'. Wow! it feels good to get that all out. I now have a new date, and approval, for 11/14/06. I can't wait... and will never think of BC/BS as being patient friendly or easy to deal with. That's my story! Mary

Mary~ Well, it ended well, you are having surgery and it will all be over with..... now YOUR time comes... 3 weeks and you will be on the losers bench, it's nice and comfy over here I'll keep the seat warm for you! Good luck with everything! Michelle Brennan

I am also a NJ State Worker with NJ Plus. I am contemplating lap band or gastric bypass (RNY). Have already gone to several seminars. Will I also have to beg for coverage of these more traditional WLS, do you think? I called NJ Plus last week with some diagnostic and procedure codes, per physician's instructions, and NJ Plus wouldn't give me any information if codes allowed coverage; just told me that the physicians would have to submit these codes when time came for precertification/approval. Where did you have your surgery, if you don't mind answering? I live in South Jersey.

You should be fine with the insurance authorization for either one of those two types. Even now, the approval for a DS is easier. They MAY ask you for for proof of a six month attempt at dieting. This is not always requested. (of course, you do have to be obese! I don't think they'll approve a 150 pounder for any of these!) I'm having surgery at NY Presbyterian in NY (used to be Columbia Pres), but I know people who have had surgery in Northern Jersey, but not in Southern Jersey. Good luck! Mary

Hi Mary, I was a stateworker woth the BC?BS PPO too. I was covered completely for RNY. I had a long history of medically supervised dieting as well as comorbidities, including arthritis, high blood pressure and asthma. I was approved on my first try....I only paid the usual co-pays.... I had my procedure at Virtua Mount Holly with Dr. Gregory Mulkalian...I understand that he no longer performs the procedure, but his former partner, Christopher Boynton does....Check him out on the boards, he has an excellent reputation... Good Luck, Kelly

I am a Nj State employee as well and went to a seminar at Atlanticare last Saturday and listened to Dr. Alex Onopchenko. Of course, there is nothing he says at this seminar about the insurance end of it. As I was going over all the paperwork to sign and review, I came across a page for my signature that I am responsible to pay Dr. "O" within 30 days of the surgery (lAP BAND)So I'm thinking he does not accept what NJPlus will pay him as "payment in full". My appointment to his office, (exit 9 off the AC EXPRESSWAY)was for this past Friday. Unfortunately, while I was enroute to his office, my cell rang and it was his secretary informing me that my 1pm appointment had to be rescheduled as he had "emergency surgery at 1pm) So i had to turn around and go back home. But the appointment card given to me at the seminar was for 11am, and therefore, should not have been canceled at all. Which may have been an omen for me afterall. I'm sure I have lots to learn about this surgery. I did get the referral for the appointment, but now I'm thinking this "referral" was not exactly the "approval" for the surgery, right? Is there a Bariatric surgeon out there in my NJ area who will actually accept payment in full from njplus?

Hi Marlene, The referral from your PCP covers the office visit, as long as this doc is in network. When you finish all his requirements, his office will apply for approval for the surgery. If he's in network, the whole cost is supposed to be covered. (except for the co-pay). If he's out of network, NJ+ is supposed to cover 70% of the fee. I'm only familiar with the northern NJ hospitals and docs, but there's at least 4 people at my workplace who had it all covered except for a $10 co-pay! My troubles were wtih getting the approval for my type of surgery, but that seems to be cleared up now.... I hope... I'm scheduled for 11/14! I don't know much about the lap band... I'm too fat for that to be successful.... but there seems to be a lot of great info, both pro and con, about each type of WLS on this board. Good luck with your search! and hang onto my email... us civil servants gotta stick together! Mary