Two insur Q's, please read!

OK, I haven't submitted to insur yet, but have spent many (exhausting) hours on the phone w/them trying to figure out if they're going to cover my VSG.  Their policy doesn't specifically exclude it, thought I know they consider it investigational, but they do cover the billing code that my surgeon submits for VSG, so I still have NO IDEA!!  I hate the waiting, but in the meantime, can I get some info on these 2 questions: 1.)  Does the insur co just look to make sure you've met their criteria (i.e. BMI, wt loss history, etc) and then go off the code?  Meaning if my surgeon's office says we want to do a VSG on this patient w/a billing code of 43843, could they say yes, we accept that code but no, she can't have the VSG? 2.)  I'm getting all this info together for an appeal, should I need it.  Would you start out with submitting all that I have with the original submission, or should I hold on to some of it so I have ammo for the appeal?  I don't mean necessary stuff (like my records showing wt loss like from LAWL), but I mean info on the VSG itself?  Let me know what you think?   Hope this makes sense, I'm a little overtired right now.  Thanks in advance for any help you can give me.  My dr's office will be submitting this to insurance next week, but they've never had a VSG insurance patient before (and they've done many of these procedures).  So I'm kind of going at this on my own, w/the help of their greating billing coordinator.  Hopefully we can make me the first one!! *Angel

Angel- i have wondered this...if they just put the code without an explanation will this work?  I mean if they cover the 43843...then what if they just fill out BCBS form and check that off and submit. it.  I have seen the form and I think it is a check off box.  I dont think that they need to add  "oh by the way we want VSG" My surgeons office and I came up with a submission plan that included letters of support from him, me and my PCP along wtih documentation on why the sleeve is not investigational and put it all in with the ORIGINAL submission.

It Makes me wonder if we just filled out the form and sent it in with a request for 43843 without all the hubaloo about it being for the sleeve blah blah blah then maybe it would have slipped through as the 43843 IS accepted (code is for gastric restrictive procedure other than VBG) and maybe we did more harm by shouting from the rooftops "we want a sleeve...we want a sleeve..." Others on that board say that their insurance companies covered it under 43843 first attempt.  They too had BCBS, but when I looked up the medical policies for their states, it said investigational too. I think if I had to do it over again, i would just put the code and send it on in and let it fly.  If they wanted to know WHICH procedure, they'd contact the docs office and ask, but if they recognized and approvable code, it might just have gone through... Food for thought...before submitting.  If they fill out the form, which BCBS has designed on their own, fully and completely, then this is an honest thing, and it is BCBS's issue for approving this code if they did not investigate for themselves what they were actually approving.  good luck on whatever you decide. 

If you send in and get a preapproval for a procedure under a code that doesn't exactly match the procedure or is for a different procedure than what is actually preformed, your insurance just won't pay the claim.  When the bill or claim is submitted it usually is accompanied by the required operative reports etc.  Your preapproval letter describes many loop holes for not paying if they don't like what the explanation looks like after the fact or surgery.  Also there is the "little" issue of insurance fraud.   Mary

Hey, thanks everyone for your input.  I'm going to go backwards up the line: Paul, thanks for your help.  I certainly hope I didn't offend you (or anyone else) by making it sound like the VSG was the be-all, end-all.  It's just the procedure I've decided is for me.  But believe me, I've been thinking exactly what you wrote.  If I have to decide between getting a procedure that my insur will cover and will provide me w/an indispensible wt loss tool, or paying for the procedure I want out of pocket, still getting the tool, but putting my family into the poor house...it's a tough one.  I appreciate your help. Mary, I don't think anyone was talking about insurance fraud.  My surgeon is submitting this w/the correct code.  It's not like I'm talking about telling the insur co I'm having an RNY, and then going to bill them for a VSG.  I've never heard of anyone on here getting a pre-approval from insur and then not getting it paid for after all is said & done.  And as far as I know they've all used this exact same code for the exact same procedure.  But I guess there's a first time for everything! Clare, I asked my billing coord the same thing you were talking about, and she totally thinks we are going to do the under-the-radar thing.  I mean, accurately and fairly (like I said above), but not be going on & on to them about it being a VSG until they ask or look on their own.  But I wouldn't say you made a mistake at all.  For every person who gets their insur to pay for a VSG, we're just that much closer to all insur co's starting to recognize it as a legitimate procedure.  And in the end, the important thing is you got it, and it was paid for.  I can't wait until I can say that!!  Though I am a little nervous, because I don't have a lot of time for an appeal, and I certainly don't have time for more than one.  So I'm hoping we don't have to convince them that they should pay for it.   Thanks again...I'll post as to what happens later!     *Angel

Hi Angel, My caution to you on this was not meant to be any kind of reflection on you or your surgeon's office staff's character.   I am only conveying unpopular information for you to be aware of.  In my surgeon's office our experience has been that just because a surgery is preapproved, does not mean there won't be a fight after the fact to actually get it paid.  The preapproval letter usually starts off with "this is not a guarantee of payment" and it is not.  They are saying that they think the procedure is medically necessary and is a benefit available on your plan.  Payment is dependant on what is actually done and if all the conditions still exist at that time.  The codes we preauthorize with are not all of the detailed codes that are actually submitted for payment.  Every part of the surgical process is scrutinized by the insurance co.  Your operative report will be looked at in great detail.  If they decide that they do not approve any part of your procedure they will have plenty of loop holes stated in your preapproval letter, to use to get out of paying.  Does this happen all of the time?  No, usually a preapproval helps much to get the actual claim paid.  But if they consider your surgery investigational you will want as much of that approved, in advance, in writing, as you can get.  Any vagueness in a preapproval will NOT help your claim go through afterward.   Actually quite the opposite.  As much detail on the procedure that you are requesting approval for would be the most helpful for you.  This information is my personal opinion from preauthorizing hundreds of bariatric surgeries that the claim was paid after the surgery. Good Luck, Mary E