Desperate for some help...

Here's my story: I'm insured with BCBS PPO through ICUBA (the benefits association for independent colleges & universities). As far as I can tell, the plan is through Pennsylvania and I'm in Florida. RNY is covered under my policy with the following: 6 months physician-supervised diet, psych eval, gallbladder ultrasound, h pylori test, etc. I started my 6 month diet in April. The diet (whi*****luded monthly visits to my PCP and nutritionist) and all of the pre-op testing was completed October 22nd. My surgeon's office sent the information to insurance and I got an approval dated November 8th. However, that approval was for a 3-day inpatient hospital stay, and my surgeon's office says that's not the letter of approval they need. The surgeon's office wants a letter from BCBS that says I meet the requirements for gastric bypass surgery and that it is covered under my policy (surgeon's office is calling this pre-determination of benefits). They will NOT schedule my surgery until they have this letter from insurance. At the same time, my insurance company is saying (1) they don't do pre-determination letters, (2) my case was already approved, and (3) the medical review team has already approved me based on my 6 month diet, pre-op testing, etc. Every time I talk to someone about this letter my surgeon needs, they give me the run-around. Here's my question: how in the heck do I get this letter done? Which department do I talk to at the insurance company (because everyone is telling me that they don't do these letters)? Is there some magic phrase I should be using to get this taken care of? It's incredibly frustrating to be approved but not have the RIGHT letter to be scheduled for surgery... help!

Insurances can be horrible to deal with...HOWEVER, I've never heard of a surgeon's office not taking the "bull by the horns" and dealing with them directly.  My surgeon's office did all of this for me.  And, my case was temporarily closed because the faxes were "too light".  I never had to deal with this (other than knowing about it because I called to check my status).  My surgeon's office fought as hard as I did. Personally, I would be tempted to call other surgeon's in the area to discuss this with them (all of them have someone in their office who deals specificially with insurance companies).  Are you totally set on this surgeon?

Sylvia, The thought has certainly crossed my mind. I hope to keep Dr. Jawad because he has the best statistics as far as mortality and complication rates in Florida. Plus, I'd hate to have to pay another "program fee" somewhere else but heck--if this isn't resolved soon, I may not have a choice. It's tough: I hang up with BCBS mad at the surgeon's office, but then I hang up with the surgeon's office mad at BCBS... if I understood this process, at least I'd know who to be mad at!! Thanks for your help!

I can totally understand your frustration.  It must be so upsetting to not know where to go for the right answers. I don't know the FL area well, I'm in Ohio.  But, from what I understand, the RNY that's done lap has become the "gold standard" for WLS and is done very easily by most surgeon's.  Since there's a lot of FL people here on OH, you might want to post a "who's a good surgeon near....." thread on the RNY board and start researching there.   The program fees...yuck.  My surgeon doesn't charge any.  I started with one who did and was very disappointed with him and his facility.  I got a lot of run around there too and a LOT of flack when I changed surgeons and decided on the DS instead of the RNY.  For me, however, that just confirmed that I made the right decision in changing surgeons. Remember, that the bariatrics field is one where lots of money can be gained by surgeons and they WILL compete for your business.  If you're having problems with the one you currently have not working for you with your insurance, you might be better off to switch. Like you, I started my 6 month diet in April and finished in October.  My paperwork was submitted on the 13th and was approved on the 21st.  I know it would not have been approved had it not been for the "insurance lady" at my surgeon's office.

IS THERE SOMEONE WHO HANDLES THE INSURANCE ISSUES @ THE SURGEON'S OFFICE? USUALLY THEY GET DIRECT ANSWERS IF WE ARENT ABLE TO. MY FRIEND CALL FOR ME (SHE'S A NURSE FOR A LOCAL PHYSICIAN) AND THEY GAVE HER WHAT SHE WANTED SO THAT I COULD GET SCHEDULED. SEE IF THEY CAN HELP YOU OUT ON THIS ONE.

Here is what you need to do.   Call the customer service number on the back of your card.  Explain to them that you have been approved by the pre cert department for a 3 day stay in hospital for the RNY and that your surgeons office will not schedule the surgery unless they have something in letter head from Blue Cross that you have meant all the requirements and that your policy allows for the surgery, if they bulk ask for a supervisor sometimes the squeek wheels have to be oiled.   If the supervisor will not help at that point ask for that person's manager and go from there.   If that does not solve the problem then file a complaint with the state your insurance is through insurance comissioners office. Hope this helps if you have any other questions that you think I can help you with let me know Vicki