Question:
Has any one with Federal BCBS been turned down after surgery?

I am 2 months post-op. My surgery was performed on 11/16/2006. I received a "Medically Necessary" Approval Letter on 10/6/2006. Last week I received a copy of a letter that was sent my doctor. It stated that that the surgery claim will not be paid until my doctor sends documentation that the WLS was medically necessary.I thought the only way an insurance company can approve someone is if that information is submitted (which my doctor's office did submit). What am I to do? My surgery was a total of $34,000. I don't have that kind of money! I would not have had the surgery if BCBS didn't approve it! I'm a basket case right now!    — Kay_dee (posted on January 16, 2007)

January 16, 2007
I had mine done utilizing BCBS. First letter after surgery said all hospital costs were denied. I called, they resubmitted and all was paid except for $100 deduct. 2nd letter said all surgeon fees were denied. I called, they resubmitted and that got paid. I had an issue with lap vs. open as when I had my surgery, BCBS wouldn't pay for lap and that's what my surgeon did. Because it was 5 years ago and my surgeon hadn't dealt with Fed BCBS much, he ate the difference between the open fee and his lap fee (almost $8000). So BCBS paid after resubmitting buy only paid the open fee. My surgeon chose to accept what BCBS paid and I ended up paying around $1600 total including pre surgery testing, deductibles, etc. So just call and have everything resubmitted. One guy I talked to at BCBS said these almost always get denied intially and it has to do with the codes the docs submit, etc. As far as I know, the only requirement that still has to be met with Fed BCBS is BMI. Good luck!
   — jutymo

January 16, 2007
hi kay, calm down hon, they are simply asking the dr's office for the supporting documents to justify the surgery. Clearly, it was medically necessary or they wouldnt have approved the surgery necessary. now they need the documents. bcbs is notorious for late payment to the provider and are very creative with stalling payment. dont let it get to you, your dr.s office should be well versed in how t get paid.,,, THEY JUST NEED TO SUBMIT THE INFORMATION THAT IS REQUESTED.
   — _blue_

January 16, 2007
Kay, Don't worry. I work for an insurance company and sometimes the medical people and the claims system do not have the same information. I would suggest you call them and talk to somebody. Some advice, write down the names of everyone you talk to and when, if you are not satisfied with the answer as to speak to a supervisor, then that person supervisor. You will get it resolved.
   — mel07

January 16, 2007
Kay, It's a great possibility that your surgeon did submit the "medically necessary" information and either it was lost or if the doctor's office faxed the information over, the entire transmission may not have succeeded. The same thing happened to me --which I thought was odd and when speaking to the person in the office that faxed over the information she of course had the confirmation page; just because you fax something and receive confirmation doesn't mean it made it to the other end. What I did was obtain a direct fax number for the person at my insurance office and provided it to my surgeon's office -- within 24 hours everything was straighten out.
   — the7thdean

January 16, 2007
Thanks for posting this, I am going through simular recently and I too have BCBS and just received a $72,000. 00 from Cedar Sinai for total costs.(maybe since I'm in Calif the costs are higher?) BCBS actually insisted I go to Cedars when I started this journey, and I had prior authorization "in writing" from BCBS, and now they are starting to retract. I have reported them immediately to the Insurance Commissioner for my state, which they are very helpful with getting papers started. They even give a list of attorneys that will assist in medical claim issues. I feel for you with this aggrevation. Take care, Roxanne
   — [Deactivated Member]

January 17, 2007
I actually just called BCBS today to ask them if my insurance covered this type of surgery if it was for medical reasons and they said NO they do not cover any of these types of surgery but i see several people out there that have been mostly covered by them. Am i going the wrong route?
   — Lcky4me

January 23, 2007
I had the gastric bypass surgery and I also have bcbs federal emplyee program. I had a letter sent to me from the insurance co. before surgery (which you can read about on my profile page) but they did pay for all of my surgery exept maybe $400 to the dr and like $200 to the hospital.
   — WannaBSlim