Insurance

Hi All - I just read a disturbing post on the main board about someone who was approved for WLS by BCBS. She went and had the surgery and then got a letter after the fact saying that it was an exclusion on her employers plan and that she owed $42,000.00

I have Keystone, which is a BCBS of PA HMO.  I rec'd the approval letter in the mail and Barix also has this.  I had also emailed my HR department in March and they said it was not excluded. 

I was re-reading my policy on Keystones online for subscribers and I decided to check my claims. They denied the chest x-ray from my PAT's.

Now I am freaking out........I would not have had the surgery if it was not covered by my insurance.
Should I just wait to see what happens??  Barix wouldn't proceed without the proper approvals, would they????
 Lisa

I don't think that Barix would have gone any farther without the proper approvals. AND if you have a copy of the approval letter you are safe! Just save that letter! Just in case...

Oh and they will probably re-submit your chest x-ray and it get approved, they may not of pre-authorized it or something crazy like that - I had Keystone when I had my surgery too and no problems at all!

Lisa,
Don't panic lots of times if you check a claim it is denied and if you through the mubo jumbo you see it icovered in another area of the billing. THat is why comapnys bill so much they know a portion will be covered. ...

I learned from reading my claim and seeing the denied for a CT scan and freaked...

Hope this helps calm your fear...

Thanks girls....I'm going to try not to stress about this.  I'm probably stressing over nothing.
Lisa

Lisa, try not to stress.. I know it's hard, but try.  I work for Aetna and there are multiple reasons why you might have gotten that denial.  It could be that they submitted it wrong.. it maybe should have been submitted as part of another claim, or not submitted at all and just included in another test or something.  If you would like to send me a PM or email a copy of the claim that was denied, I might be able to help you interpret it.  My email address is [email protected]

If you have that letter of approval, the onus is on them, not you.  As long as you checked with your HR dept and they said it's not excluded, you're good to go. Most good programs will not proceed without that letter. And once you get that letter, the insurance company is NOW legally on shaky ground if they deny. But I think you are ok. My entire surgeons fee was denied because of a simple paperwork snafu. You wanted to see freaking out! $`14,000!!!! But I was assured it was just a technicality. Relax!

I have Keystone Healthplan East.  Go back on My IBX where you checked your claimed and read your specific policy - its going to be on that same site.  Unless your employer specifically has a rider excluding WLS - its definitely covered  by IBC.  Trust me, I can't speak for Barix, but IBC would not have given a pre-certification if you weren't covered and my understanding of the law/regulations in this area is that if a doctor goes ahead and does a surgery that requires pre-authorization - which is true for WLS  for Keystone Healthplan East without getting the pre-authorization then that surgery is on the hospital or surgical practice - not the patient.  Be at peace.

Rhonda