BCBS PA - Highmark PPO Blue

I posted this in Insurance, but thought I might have better luck here. Thanks! -BG

Some questions if you have the same insurance.

1- Diet:  6 months with 7 visits or 6 visits? 
I have a LB friend attending a different program at Magee (same ins.) and she was told she only has to come for 6 visits (so 5 full months).  I'm reading here that most people do a full 6 mo. (180 days), so including the initial weigh-in that's 7 visits.  Which is it?  I'd love to cut a month off this as my 2 oldest graduate the next month, but I don't want to be denied.

2- Surgery Costs:
I've been told this is completely covered.  What costs did you have to pay as your copay/percentage for your surgery...I'm trying to get a ballpark of what to expect. 

3- Fills:
I've been told these are covered 100% as long as they are medically necessary.  What exactly does that mean and what documentation did you have to provide to get these covered?

You're in luck...I'm the insurance expert as I worked for BCBS and Guardian for 10 years.

The answer to all your questions basically comes down to the same answer - It all depends on not only your insurance carrier but the policy itself. You may have 100 people covered under Highmark BCBS and I can almost guarantee you that there will be 100 different policies with completely different coverages, copays, exclusions and requirements. There is just no way to judge what your coverage will be based on someone elses coverage even though they have the same company as you do.

So for your first question - you need to specifically ask your insurance company what the requirement is. Again, don't go by what your friend had to do or didn't have to do because it all depends on what your contract stipulates. Your insurance company should be able to break it down for you so that you know exactly how months and/or visits you will need to complete prior to submitting for approval. If the rep you're speaking to can't tell you then ask to speak with a senior rep. If they still can't tell you then ask for a supervisor.

Your 2nd question - Only the insurance company can give you a better idea as to what your costs will be. Again, it will all depend on your policy. The surgery may be covered at 100% but you should also find out what the coverage is for the hospital stay as well as the anesthesiologist. These things may not be covered at 100%.

The last question on fills - They are a necessary part of being successful after the initial surgery but I personally have never heard of having to prove medical necessity for them. Ask the insurance company to tell you specifically what they need to prove necessity because what person X might have had to submit will not necessarily be what you need to submit. Also and this is not meant to upset you in any way but many insurance companies are moving away from paying for fills. This could be why they're saying you'll need to prove medical necessity (they may very well have no intention of paying for it ) so get the information ahead of time to prevent any problems with being billed by the surgeon.

Whatever you do - Write down the date, the time, and the name of rep you spoke to and the information they gave you anytime you call them. It comes in handy believe me. Good luck to you!!

WOW Valerie...that was SOOOO helpful!  I'm making a list now to call the insurance co. on Monday!  I knew BCBS had many policies, even in the same state, but no one ever mentioned that once I got to the Highmark level in the same city that I may still have a different policy.  Thanks for all the tips.  One last question...

I've been reading a lot that people get different answers from different people at the insurance co., do I need to call more than once to double-check, or should I include the documentation (things you suggested; who when) as part of my paperwork I submit?  "Spoke to ....at....date... and she confirmed...."?

Most importantly WAY TO GO!!!!  On your weight loss...what an inspiration!!! 

Glad I could help. Insurance can be very tricky!!

Getting different answers from different reps is very common. It's unfortunate but common none the less. Not to bore you to death but...The problem is that customer service jobs in the insurance industry have a very high turn over rate. They're very stressful jobs and it takes a thick skin to last very long in that position and most people don't make it very long. Because of that..these companies are constantly having to hire and train new people and most of the time they're being rushed thru training to get them out onto the floor to start taking calls. In turn, these new reps more often than not will end up giving out the wrong information because they lack the proper training.

Anywho - my personal opinion is that including all the information you get when you submit for authorization won't hurt and can only help you. If you include that 3 different reps verified that this and that were covered procedures, even if it's not, they will most likely approve it because of what you were told. This is sort of a behind the scenes secret that most people don't know. I've seen it happen many many times before and I've had to cut checks for patients on more than one occasion to reimburse them for services that were not actually covered but because they were verified as being covered, we had to pay for them. I say you should include it but that's totally up to you and your surgeon. Most likely, your surgeon probably has a standard authorization form they use so they may not want to do this for you but you can either write your own letter and tell your surgeon you would like it included with the pre-authorization request or if something heaven forbid happens and they deny you, you can send it in with your appeal.

If you have any other questions, please don't hesitate to ask!!

And before I forget......Thanks so much for the kind words! They're appreciated very much!

I have BC of NE Pa and Highmark BS. I had RNY surgery. When I looked into WLS they were not paying or approving lapbands. 

Valerie, doesn`t BC pay the hospital and BS pay the doctor? 

Many many moons ago, BC was a separate entity from BS and yes each were only responsible for either hospital charges or doctors bills. However back in the mid 1960's, they merged to become BCBS and it's my understanding that although some plans like Highmark still have policies known only as only BS, they are still in fact BCBS and there is no longer any separation. There are certain cir****tances though such a person having Medicare, that the plan would in fact only cover certain charges such as doctor but that's because it's what the policy itself covers.

Insurance is a headache to say the least. When my husband and I had our surgeries we were both covered under Horizon BCBS and had no trouble getting approval yet one of my friends tried to get approved and couldn't no matter what she did. I kept trying to explain to her that it was because of the policy her employer purchased. In their contract, it specifically excluded any WLS what so ever, whether medically necessary or not. She didn't understand though. If you look around the site, you'll find many people who were approved for a lap band or RNY with X insurance and then plenty of others who were denied. It's on a policy by policy basis.

LOL I should know all that but don`t as my wife is a Benefits person at work, my DIL is the BC/BS person at Warren Hosp, my Mom runs a doctors office in Easton and my sister runs a Hospice program. I guess I should pay attention when they talk.

My brother worked for Guardian off 512 and Aetna off Cedar Crest and Sigma off Airport Rd.

LOL!! You're not alone. My husband is the same way. When I was still with BCBS, all he knew about what I did for a living was that I did "that stuff with the benefits"...lol. I think insurance is just so mind numbing that most people tend to tune us out..lol

I was with Guardian in Bldg 2 off of 512 for about 2 years in their short term disability department. What department did your brother work in? It's a small world, maybe we actually know each other??

Valerie, I'm so glad you admitted to working in the insurance industry.  I was afraid to admit that I do, too.  I work for Aetna and get the same questions all the time.  Everyone wants me to tell them why something isn't covered for them and why it is for someone else.  Or how to get something paid.  I did customer service for about 6 years.  Now I do plan set up and am lucky enough to work from home.  You are right about different plans, different employers, different policies.  Even some people who work for the same company can have a different policy.  So everyone needs to verify the information with their own insurance company.  

I actually am covered under my husband's Blue Cross policy because it is better than my Aetna policy. LOL!! and cheaper! Who would've thought!

Nah, you don't need to be afraid of anything on this board. If anything, everyone here will appreciate your background and the guidance you can offer. I used to try and help people out on the main board all the time because they would post insurance questions and sure enough you had all these people giving them all sorts of incorrect info but I gave that up after some woman ripped me a new one and told me I had no idea what I was talking about..Ummm ok, 10 years in the industry and I don't know what I'm talking about??

I've been out of insurance for just a few years now but honestly I really miss it. I loved the work I did with BCBS and Guardian wasn't all that bad either. I tried to get into Cigna and Aetna a few months ago but never heard anything back from either of them which I found really weird because I was a Benefits Analyst for 8 years(which kinda sounds alot like what you do) and a Short Term Disability Specialist for almost 2. It's not like I'm a complete dim wit when it comes to knowing the business...lol...But I guess with the economy and all being the way it is, there just isn't a huge hiring frenzy so I figured on waiting until things begin to get a little better and then try again. Hey, who knows? Maybe we'll be coworkers someday! Well long distance since you work from home..lol

OMG! When I was with Guardian, it was the same thing..We had better and cheaper insurance through my husbands employer than if we had gone through mine. There's just something soo wrong about that! lol.