Horizon Blue Cross Blue Shield NJ HMO

I need some advice as to what I can do next. I live in NJ, on the border of Staten Island. I chose Dr. Heather McMullen in Staten Island because they are only 11 miles from my house and because their waiting period was not as long as some here in NJ. I had already been through the whole waiting process with Dr. Robert Brolin who decided to go out of network and I don't have out of network benefits. I started all over and went to Dr. McMullen. I have been back and forth and have had every pre-op test done. I was just days away from having the surgery scheduled when my insurance company (BCBSNJ) informed me that they would approve it if it is done in NJ, but not in NY. NO ONE ever told me that I had to stay in NJ and I even had a referral from my primary care doctor. When I called them to find out if the surgery is covered, they did not say it wouldn't be covered in NY. I don't think it's fair that I should have to start all over with a new surgeon and go through this whole waiting process again. It was not my fault. Can this type of denial be fought and won? If not, is there a chance of finding a surgeon in NJ who will take over my case from where it stands now, using all of my test results, and possibly do my surgery in 5-6 weeks as it was before?

Michelle: I'm sorry that you are going through a rough time. I had to fight with Horizon BCBSNJ for three months to get approval, calling them eveyday, threatening lawsuits, appeals, etc. Keep calling them, appeal, file a complaint of "bad faith" practices with the New Jersey Department of Insurance, www.state.nj.us . I live in South Jersey, near Philadelphia, and Horizon BCBSNJ has several Philadelphia hospitals that are in-network, so I can't imagine why there would not be any New York hospitals in-network. As for surgeons, many are opting to be out-of-network. My surgeon Dr. Vishal Mehta, is excellent. Dr. Mehta operates at St. Peter's in New Brunswick with an office in Somerset. However, Dr. Mehta is out-of-network, but St. Peter's is in-network. Therefore, your only out-of-pocket costs will be $100 for te consultation and $2500 up front costs towards the surgery. Thereafter, Dr. Mehta accepts whatever the insurance pays him, he does not balance bill the patients. Usually you can get consults and surgery with Dr. Mehta quickly, if interested, his phone number is (732) 745-0999, ask for Lulu and tell her everything that you already have completed. New Jersey has passed a law that requires insurance companies to cover all hospital related expenses as in-network, if it is an in-network hospital, whether the surgeon is in-network or not. Whatever you decide to do, don't give up. Keep fighting Horizon BCBSNJ, and get the NJ Department of Insurance involved. Tell Horizon that yu feel that they are acting in "bad faith" and that you intend to takke all available action until you get approved.

Michelle - Dr. McMullen was my surgeon and I am 8 weeks post op Lap RNY and down 48 pounds. She is fantastic and worth fighting for - the whole team in SI was terrific. I also live in NJ, but had my surgery in Staten Island. Although Aetna was my insurance, they did not make any qualifications about NY vs NJ. I think it is worth a fight. Ask to speak to a supervisor and ask them to show you from your SPD (summary of plan description) that you can only seek medical from NJ. I don't think there is such a thing. Throw your weight around a bit (make is useful) and see if you can get them to agree. It may also be worth it to get your employer's HR benefit advocate involved and on your side. That can only help. From someone who used to be in HR benefits, it can often make a difference. Good luck!