Research doesn't lie- research, then decide for yourself!

If I recall correctly...and these days, who knows...I asked him why the Delano facility was not a CoE and it was because although HE had like ten times as many DS surgeries under his belt as they required, his partner surgeon did not have the required 100.   (Or whatever the number was.)

But that was then and now he's at an additional hospital and, I assume, there is no other surgeon there who is experienced in the DS.


This makes me a bit suspicious.  Say there's some big facility that has two doctors who have done the required number of bands...then a couple of relatively inexperienced doctors who have just started doing the band are allowed to do the surgery and BC covers it and the doctors have the benefit of the experience of the others...but what makes having a procedure done by one of a couple of inexperienced surgeons "better" than a single really experienced surgeon whose partners have "only" done 80 procedures rather than 100?

It's all a bull**** shell game, with BCBS limiting patients to hospitals with which they have preferred (cheap) reimbursement rates, and the hospitals being willing to put up with lousy reimbursement rates in exchange for volume of patients steered to them.

Sue,

This is exactly the help I need.  I got the list of COE hospitals and I printed the DS surgeons from the dsfact.com. However, I have only been able to talk to the Anthem BC customer service people.  I had them look up each of the DS surgeons and no one was on the plan.  The exeption is that Dr. Keshishian is a contracted BC provider and if he does my hernia surgery in Glendale at the Glendale Valley Hospital, then that is covered.  I have a consultation scheduled on the 15th.  The office tells me that we can negotiate with the hospital on the price I have to pay out of pocket.  After the surgery is when I start the fight with the insurance to approve.  However, that means I have to pay a lot of money up front too.  28k pefore negotiations.  

I've given up on Dr. Rabkin because even though he can do the surgery in El Camino at a BC facility, he is not contracted with any insurance.  I kind of felt like he is top notch, but because of that, doesn't feel like he has to deal with insurances.

I am the subscriber on my insurance and all of my plans that are available are Cal Pers and all have the Center of Excellence clause.  Customer service says that I can't even go outside of CA because COE is only in CA. 

Sue,  can you email me with the details of what you did. I really think this is what I'm going to have to do too.  [email protected].  I work for the Cal State University system.  Thought that if I switched to a PPO that I wouldn't have these issues, wrong..  Anyone know of another private insurance that I could pay for who doesn't deny obese people that could cover this insurnance? hmm

Most of what I had was just documents now stuck inside my old computer.

Okay, you might as well know how TRULY insane I am:

When I know that I am right, I don't give up.  So..I went to Yahoo Finance and found BC of CA and then found officers' name and phone numbers and e-mails.  The chief medical office to whom I wrote originally has been replaced.  (Apparently the current guy is Kurt Tamaru, MD.)

I believe I found their legal department and some phone numbers.  (Often you can find that stuff via their press releases.)

I think my positions would just be:
1--my policy says you will cover the Duodenal Switch surgery (a bariatric surgery);
2--my policy says that bariatric surgery must be at a COE in California;
3--you have no COEs in the entire state where the Duodenal Switch is performed;
4--you wrote the contract knowing all of the above...

THEREFORE, BC seems to be telling me (and every other person on this contract) that it will provide coverage right before they tell me (and everyone else) that they will not provide coverage for that procedure which does not sound like that particular part of the negotiations were done in good faith.

Given that no COEs where this "covered" procedure is performed currently exist, BC should cover this procedure by an in-network surgeon at the in-network facility that is currently closest to meeting the COE criteria, for example, where hundreds or thousands of these procedures have been performed over the years without any ongoing problems.  


I would also find out which CalPERS board member is in charge of the Health Benefits--I couldn't figure it out from their website--contact that office and learn where to go to find someone who might be able to assist me in this matter can be contacted.  I WOULD NOT START AT THE BOTTOM.  (That always takes longer and all the people who eventually get their decisions reversed get pissed.)

You've been lied to. Delano is a COE facility for Blue Cross/Blue Shield. I had my surgery there and has the same requirements.

You may be right, but their website lists them as a "Center of Excellence" per the ASBS.  That isn't the same as a BC "Center of Expertise," although they could be both. 

Way back when, the ASBS was pushing for "Centers of Excellence," and then in 2006, Medicare required that bariatric surgery be performed in one of those "Center of Excellence" hospitals.

But, the insurance companies outspent them and simultaneously declared the hospitals they could "negotiate down" to bare bones payments as "Centers of Expertise."  Cute how they had the same initials.

Confusion has reigned since then re the CoE label.  DRMC was NOT a BC CoE when I had surgery...but well could be one by now.  (and I was BV then, Anthem BC now...never Blue Shield BC and so even that could make a difference.)

Yes,
Even the customer service rep at Anthem BC had a difficult time trying to explain if there was a difference for COE, Center of Excellence or Center of Expertise and CME, Center of Medical Excellence (older term).  They don't know mu*****ustomer service.

My plan is Cal Pers, Anthem Blue Cross PPO, prudent buyer.  I guess there are so many diff. plans at BC.  Anyhow, all the CalPers plans that I can subscribe to in the Cal State System all have the COE bariatric clause.  

My hernia surgery will be covered at 80/20 when done with Dr. K in Glendale because it is a general surgery.  I hope I can negotiate a big break.

Here are the COE hospitals listed for bariatric surgery  on my plan (I already had RNY 10 years ago)
LA County, St. Johns Regional in Oxnard, Cedars Sinai, Hunington Memorial, Marina Del Rey, Providence St. Joseph,  USC, Tri City Regional, Torrance Memorial, Ronad Regan UCLA.
San Diego County, Alvarado, Scripps Mercy (where I had my original surgery), Pomerado, and Sharp Memorial.
Pleasington, CA - ValleyCare Medical
Chico - Enoe Medical Center
Fresno - Fresno Heart, St. Agnes and Clovis Community Hospt.
Orange County - UC Irvine, Orange Coast Memorial, Fountain Valley Reg., and Chapman Med Ctr.
Riverside - Desert Regional MC, Parkview Comm.
Sacramento - Mercy San Juan
Santa Clara - El Camino Hospital, Good Samitan, and Stanford

Seems like a lot, They expect me to contact all these hospitals, but I just went to dsfacts.com, pulled up the list of surgeons who do the DS, and none use these hospitals.

Now, Dr. Rabkin's office, first told me that they could perform the surgery at El Camino for their BC patients, but then Matt seemed to change his story after he verified my insurance.  So, I may have to follow up again on that, if I decide to.

Pam (want to be thin and healthier again)

Is it even possible to revise from a DS to an RNY? Not sure why anyone would want to but still...

xoxo,
Katie

Yes, it's possible---but it would be really stupid. (*grin*)

I had the exact same experience. I KNEW I wanted the DS, I have a friend that had it in about 2003 and to this day still looks great... but my insurance would only cover the RNY or lap band, so in desperation to have whatever I could get, I had RNY. it was successful for a while, I lost 105 lbs and was within a few lbs of my goal, but I have gained almost 40 back (probably more if you count lost muscle weight) . my problem right now is I am just starting to consider the DS revision and I have no idea what the criteria is that they will do  the revision and if insurance will pay. I weight almost 180 now (5'4") and I look and feel like crap. I said I would never do a revision, but I just can't get my weight back down, where before I was able to get back down to close to my original low weight. If you or anyone else knows the criteria that makes a person eligible for RNY to DS revision, please contact me
It would be kind of sad and funny if my insurance will now cover the DS and cover my revision, since it is what I originally wanted and they wouldnt cover it.