Usual and customary fee for bariatric surgery

Hi everyone, My insurance company, Horizon Blue Cross & Blue Shield, paid $5,200 of the $12,500 billed for my laparoscopic gastric bypass surgery. They have denied my verbal appeal to pay my surgeon more. My next step is the letter appeal, however, I need to know what other surgeon's are charging and receiving, so that I can write an informed letter of appeal. I appreciate any information people can offer. Thank you for taking the time to read and hopefully respond to this message. Kathy Rivera

When u orginally got approved for the surgery, didn't they tell you how much they would be covering?? I just got approved through them and I am ASSUMING that they will cover it all. I had actually asked the doctor that question and he said not to worry about. I'm thinking that maybe I should be worried. I heard when I was checking around that $12,500.00 is standard price. Let me know what happens. Sharon

Hi Sharon, Thanks for responding. No, BC never tells me how much they will pay. I just received notice that they denied my appeal and that the 5,200 they paid is the maximum benfit allowance for the surgery performed. I work for the State, so I don't know if your plan is any different. As we speak, I am on hold with BC to get some clarification. In the mean time, you may want to check with BC regarding the specifics of your plan. No matter what the outcome is, I'm still glad that I had the procedure. It was a life saving and life changing experience. Even if I have to fork over more money it was totally worth it. Best of luck, Kathy Rivera

what does your policy say? Was your doctor in-network? I have cigna, and my policy covers 90% of in-network docs etc with a maximum yearly out of pocket of $1000. Out of network I believe it would be 80%.

Hi Linda, Thanks for responding. No, my Doctor is out of network, but that isn't an issue because my insurance is a traditional plan and not a managed care plan. I just received a denial for the appeal but am trying to clarify the reason. It may have come down to coding. Nice of the insurance company to tell me this now. Kathy Rivera

Hi Kathy, I am also going to Dr Brolin. To my knowledge $12,500. is the going rate if not higher. I know he is out of network so my insurance CIGNA will only pay 80%. That is if they ever approve me. Please Email me if you would I would love to know how it went with Dr Brolin. THANKS and GOOD LUCK, Georgette

Hi Georgette, Thanks for responding. Everything went well with Dr. Brolin. He doesn't have much of a personality, but I'm not looking to be buddies with the guy. He was thorough and was willing to answer any questions. My surgery went very well. I was admitted early on a Monday morning and was discharged by Wednesday afternoon. I had the laparoscopic procedure and did not require ICU care. It's been 6 1/2 months and I have had little or no complications. I don't tolerate pork very well, so I just don't eat it. Scrambled eggs as well, but I can eat them over easy. As I told Sharon, even if I have to pay the balance, it was the best thing I could have ever done for myself. Let me know when your surgery is. Best of Luck, Kathy Rivera

hi, I am also a state employee, I know it is too late for you but I post this in case there are other preops reading this. I have BCBS also as a state employee. When i started looking for surgeons, I found that Dr. Brolin was not on networks anymore after his move from St. Peters. I found that Dr. Bertha, (Morristown Memorial) was in network for NJ PLUS, during the yearly open enrollment I swithched to BCBS NJPLUS from the traditional plan. I paid $0 for the surgery, hospital and followups. Roger

Hi Roger, Thanks for writing back. I knew that Dr. Brolin had pulled out of all insurances, however, after 3 different consultations, I felt he was the best surgeon for me. So far so good. 61/2 months and no complications. I too recently switched to NJ Plus b/c I'm tired of paying 200/month for the insurance, having to pay 2,000 out of pocket before I receive 100% reimbursement and b/c BC does not pay for alot of preventative services. I know you paid $0 for the surgery etc., but do you know what your sugery cost? I'm trying to establish if my fee was about the norm. I hope you get a chance to write back. Thanks very much, Kathy Rivera