Revision Caught between a rock and a hard place???

Hello to all, Well, I received a letter last week from BCBS FEP.  It stated that Gastric restriction surgery is considered an out patient procedure and they do not review or give approval for payment until after the procedure is done and all lab and path reports are reviewed.  They do have the medical necessity letter from my surgeon plus all the other back up paperwork that the surgeons office sent. Now, it is still up in the air?  How does the surgeons office get approval if the insurance company?  The hospital or the surgeon will not do the surgery without pre-authorization. What am I supposed to do now?  The insurance girl at the surgeons office said to let her keep working on it awhile longer.  But what else can she do? I tell you what?  This is the pits! Sorry for venting. Barbara Brewer RNY 5/20/03 Waiting on possible revision

Have you researched into the DS?  I had a revision from the RNY to the DS with wonderful results, of course you want to use a surgeon who is experienced in the DS proceedure AND revisions, but I too had FEP BC so I know they cover it.  Also, it is in-patient so no problem there,  Go to the DS baord and check it out. Beth

Does that mean as long as the surgery is inpatient they should preapprove? I hope so... I really dont know what difference it makes though. They need to back up what they put in writing. They say they cover this. This is for BCBS Federal Basic. It doesnt say anything about deciding AFTER the surgery whether they will cover it or not. GRRRR

Gastric restrictive procedures, gastric malabsorptive

procedures, and combination restrictive and

malabsorptive procedures to treat morbid obesity –

a condition in which an individual has a Body Mass

Index (BMI) of 40 or more, or an individual with a

BMI of 35 or more with co-morbidities who has

failed conservative treatment; eligible members

must be age 18 or over. Benefits are also available

for diagnostic studies and a psychological

examination performed prior to the procedure to

determine if the patient is a candidate for the

procedure.

 

Hi Barbara, I'm in the same boat as you! My surgeon had to file an appeal on my behalf and the insurance company (BC/BS FEP) said they would review the appeal as a courtesy to myself and the surgeon (but they didn't HAVE to). Basically, the procedure does not have to have a prior approval but without one if they can call the procedure investigational after the fact and refuse to pay and we are stuck paying out of pocket whether we like it or not. My appeal has been "in review" for 2 solid months now and the explanation they have given me for that is since it is being done as a courtesy to me any other appeals will take priority and they can take as long as they want to make their decision. Today the customer service rep basically told me they would not give me a time frame for a decision but if my surgeon called them he could talk with a physician on the review board and he might get more info than I could.  I just put a call in to my surgeon and I am sure he will be giving them a call sometime today. I'll let you know if I hear anything else!

Thanks Molly for your response.  I will check with Dr Nick's insurance person again and see where she is at...Like I mentioned before Baylor, Plano Texas and Dr Nick Nicholson do not do surgeries without prior pre-certification.  Insurance companies do their best to keep from spending anymore more than than have too. Yes, please keep me informed of your situation too. Barbara

Hi Barbara - I had RNY 6/03.  I have BCBS Fed as well and got the same response.  My dr's insurance person thought it was a "preauthorization" and they went ahead w/the surgery.  Afterward, they sent int the operative notes and all other required documentation and it was turned down.  After 2 years of fighting w/the insurance the final decision was they would not cover it - didn't see a medical necessity.  So I've been making payments ever since.  As for my dr's office - they wouldn't accept any further fed plans until they were assured of getting absolute preauthorization - I'm told it was about 2 years.  They said it's the worse insurance - the BCBS Fed plan.  As for my surgeon, he never billed me -- but I was stuck w/the hospital and anesthesiologist bills.  I am now seeking a revision but seriously doubt the insurance would consider it.  Good luck.  Let me know what happens!!  Carolyn 

Thank you for your reponse Carolyn. Now I know why my Dr and his insurance person is being so careful about mine.  I think this has happened to them at Baylor Plano before that the patient got stuck with the whole bill and they don't want that to happen. I will let you know the outcome. Barbara

Please keep me posted.  I'll keep my fingers crossed for you!