New to forums... Insurance nightmare

Hi everyone, I'm new here. A friend of mine that is seven years post op recommended I join.

As I'm sure everyone else did, I took years making this decision. I saw my PCP to discuss it. He was 110% on board BUT gave me some depressing information. He told me that my particular insurance medical group very rarely approves WLS. He told me that I would have to go through six months of classes (which I expected), but that after the end of those classes I still stood a very good chance of being denied. Even though my BMI is 45.5 and I'm diabetic. He said that this particular insurance group just hardly ever approves anyone's WLS.t

After talking to my postop friend, she recommended changing to a PPO during open enrollment in November. And I agreed with her, I thought it was a great idea. I started researching the different insurance plans we have available to us and found that out of the 20 or so different plans we have available to us (federal government employee) not one of them was a good old-fashioned PPO. The closest thing I found was an FFS (fees for service) with option of PPO.

Does anyone even have an idea of how an FFS works? I am beyond confused and don't know where to turn for answers or help in understanding these insurance plans.

I am a retired Federal worker. I chose a local HMO. They denied my request for bariatriac surgery in 2013, but approved it this year.

Blue Cross/Blue Shield FEP. There's a PPO option, they cover the surgery, and they won't deny it as long as you meet the criteria, which you do.

The WL surgeons offices know better than anyone. Mine had navigators to help go through the insurance stuff. I would start with them, and have them tell you which hurdles you have. They work with the insurance issues for a living. I would go to the info meetings offered by your local WLsurgeons and get started. I would suggest NOT doing the 6 months of diet until you meet with your surgeon. It will be that office that obtains the insurance approval for you, not your PCP. Don't waste anymore time.

BC/BS FEP, no problems at all and a quick approval :)

I'm also a federal employee. I have BCBS basic. The first doctor I went to was a nightmare experience. BCBS kept denying the surgery even though I wasn't having it for weight loss but for severe reflux etc. BCBS wanted me to do a 3 month supervised diet so I completed that and they still denied the surgery. He even did a peer to peer review and it was still denied, I wrote an appeals letter with no change. I then went to another doctor for a second opinion which he concurred that I have no choice but to have wls. I talked to the insurance person at the new dr office and brought all the denial letters to him. He was like no problem I will get this approved. In less then a month I was approved and scheduled for surgery in a couple of weeks. This after dealing with BCBS and the other dr office for over a year and a half.

It was amazing how quickly this new insurance guy at my dr office was able to get things done. Now this new dr did order more testing for reflux and to find out how my esophagus anatomy was so maybe that had some part in the fast approval I don't know but to me it was like a miracle. Carl (dr office insurance person) said you have to know how to present it to the insurance companies and that he loves to fight with insurance companies for approval. LOL.

This to say keep trying don't give up. Good luck!

I had a similar experience at my surgeon's office - I was an ideal candidate and they knew the insurance requirements so i did not have to go to another doctor. Everyone needs a Carl!!

Thank you all for your replies. I'm going to look closer at our insurance options to see if any that were mentioned are available. Next week I plan to call the serguons office and see if I can get any help in figuring this out from their insurance department.

They called me yesterday to set up classes for the "weight management program". I asked the woman straight out how often she sees people get approved through this insurance group. Her response made me feel even more helpless. She said that this past year she's seen 3 people get approved that ctompleted the classes. 3 people in almost a year out of hundreds. The only hope I have is to figure out and find a new insurance to switch to next month.