Question:
Anyone with BCBS-Federal PPO that has experienced

Now I am not only thoroughly confused, but ANGRY and don't know who or what to believe anymore!! I was informed just now that I HAVE NOT BEEN APPROVED for WLS scheduled on Sept 3rd, and my claim will not "actually be approved" until AFTER the surgery and it is submitted to BCBS of Georgia-Federal...and get this-NOW a pre-determination AND pre-approval letter is REQUIRED!! I wonder if this is because I'm going out of network?? Doesn't matter..I'm still gonna do it! I'm so so SOOOO sick of this madness!!! Anyone else experience this obstacle?? Thank God for my faith in HIM, 'cause I'm still gonna have THIS SURGERY!!! Hadiyah    — yourdivaness (posted on July 3, 2002)

July 3, 2002
Hello!!! I just don't know that I would feel comfortable going through with a surgery "they haven't approved", what if they decide for whatever reason to not approve your surgery. Being left holding the bag would be devastating to me. I'd get in touch with my Insurance Commissioners Office, www.gainsurance.org, there is a place to file a complaint on the website. Fill it out explaining what your insurance company has told you and that you fear they may decide not to approve after the fact. You might also want to check out SB210 HMO's-certain disclosures, access to out of network providers - www2.state.ga.us/legis/1999_00/leg/fulltext/sb210_ap.htm - even though you have a PPO, this may also apply in your situation. You could question your insurance commissioner about this also. I may be overcautious, but I would want to know that my butt is covered, I don't trust the insurance business as far as I could throw it. I hope and pray everything works out for you, you are worthy to receive the best, most wonderful life you can make for yourself and your health. Best wishes, Jo-Dee
   — tinyjo

July 3, 2002
Hadiyah, BC/BS Fed is usually one of the easiest insurances to get approval, but they are right, they don't actually approve before hand. The doc submits after surgery for reimbursement. Check with your surgeon on how his office handles BC/BS Fed. I can't believe he doesn't have experience with this one and will know what to submit and when for approval. I have BC/BS Fed in Va and had zero problems with approval-payment after the surgery. It may be the extra paperwork is needed because you are out of network-just keep in mind that you will pay more out of network. Can you find a surgeon in network? One thing I do not like about BC/BS is that they will pay 80% of out of network costs, but those costs are what BC/BS has arranged with in-network docs, which is hugely reduced from the actual cost, so many out of network docs expect you to make up the difference. Check this out.
   — Cindy R.

July 3, 2002
Federal Blue Cross quit doing pre-determinations for WLS a couple of years ago. But, if your BMI is over 40 and if you are over the age of 18 -- then the surgery is a covered procedure -- no diet history, no co-morbidities, no letter of necessity from you PCP required. I went through the same things your going through when I had my surgery 10 months ago. I will say that BC of Alabama which manages my plan did not have their system set up to deal with the WLS claims -- the system automatically denied the surgery because of the morbid obesity diagnosis code. I did have to call several times and the customer service rep had to manually override the system and resubmit the claims. Everything was covered eventually though! I have not heard of people in other states having this problem, but everyone in AL with Federal BC has had similar problems. Your out of pocket expenses will be greater though since you are going out of network. I used a BC PPO physician and hospital and my out of pocket expenses were between $500 and $1000.
   — Denise C.

July 5, 2002
In 2002, Blue Cross split changed the options from high and standard to standard and basic. I had WLS surgery last year under standard--it took a while to get the codes right, but it was taken care of. Now, as I understand the plans, standard option covers WLS while basic option does not. If you have standard, you should be covered.
   — Mary N.

June 18, 2003
Original Poster Here: I just want to say “Thank You” to ALL of you, for taking the time to respond to my question(s). Oftentimes, I’m so busy reading and responding to others, that I’m unable to get back to my own posts. I try to make time for others just as others have taken time for me both pre and post-operatively. You clicked on and shared your knowledge, when you could have simply moved on to the next question(s) from others. I appreciate you! LAP RNY 9/3/02 265/158/115-126 and currently on a plateau...Luv, Prayers and {{{HUGS}}} Hadiyah McCutcheon, a.k.a.~~
   — yourdivaness