Why a "Center of Excellence"?

Well, I have been waiting for the first of the year so I could switch insrance to Blue Cross PPO Prudent Buyer. I spoke to the surgeons office a few months ago and they confirmed Blue Cross PPO is one of the easier ones to get approved for surgery. I had an appointment for tomorrow for my consultation. I checked the requirements for the surgery on the Blue Cross web site for my plan. It states I must use a center of excellence. I called my surgeons office and was told that I must use the center of excellence and they are not one. I had to cancel my appointment. Does anyone know 1)  Must you use a center of excellence if they are about 100 miles from your home? Has anyone questioned this with their insurance? 2) Has anyone checked this out with the Insurance Commisioner for the state of California? Is this something we could appeal? 3)  What is the purpose of going to a center of excellence? Is it just because the insurance has contracted with this hospital? I know people in Modesto have gone to Memorial Medicaol Center quite alot and they just have a different Blue Cross plan I guess. My supervisor had the surgery 3 years ago using the same Blue Cross PPO that our employer still offers, she did not have to go to the center of excellence at that time. Any responses would be great.  Thank you,  Kim

Hi - I went through the same situation that you are going through now.  I was a patient of Dr. Coates, however, when my insurance changed to BCBS PPO I had to switch also.   From my experience, they are very strict about the center of excellence policy, however my policy from my job provides reimbursement provisions for the travel ( mileage, hotel)  you may want to look into that.

From what I can tell, the center of excellence is "supposed" to provide you with a better level of care -for bariatric patience.  

Any other questions, post  them.  Good Luck

 

 

You may need to come to Fresno Clovis Community Hospital & Saint Agnes are both Centers of Excellence for BCBS. I have also heard that Fresno Surgery Center is one, but they aren't on the list. Centers of Excellence have to meet very specific criteria related to # of procedures performed which (according to several studies) is the # 1 predictor of positive surgical outcomes. There are several other requirements in staffing, etc. It's not a bad thing. Good Luck, DJ

Thanks to everyone for the response and yes, I am going to Fresno. I went to my WLS support meeting here in Modesto last Tuesday night. and two of the leaders both went to Dr. Higa, he was highly recomended so I made an appointment, it is Feb. 25. I would like to go to Fresno Heart Hospital, it is a Center of Excellence and I hear it is very nice. I received the paperwork from Dr. Higa's office, it looks like I will be able to do the psych eval in Modesto and the nutrition eval in Merced, that was good news. Thanks again,  Kim B.

Sounds like good news I just had my appt. with Dr. Boone, Higa's associate. Both of them were recommended to me by all 3 of the nurses in my family who have worked with Bariatric patients in some form or another. Boone doesn't do the volume that Higa does, but he spends more time with each pt. Both are exceptional surgeons according to all accounts. I have heard good things about Heart Hospital as well. Good Luck DJ

COA only applies to medicare.not regular plans yet, ThANKGOD. Revisions, you can go to any doc under medicare.  dont ask me, asbs cut the deal.