Question:
Insurance experts - please respond!
I have not had a consult with my surgeon yet, although they do have a packet of information which I filled out back in August. They called my insurance themselves a couple of months ago, and were told a benefit was available under the Major Medical portion, which would mean I will have out-of-pocket expenses. I decided to check with my insurance company, Highmark BC/BS (traditional), first, to see if WLS is a covered service. I did not tell them I have been in contact with the surgeon. I have been waiting for an answer on this inquiry since October 30. I call them every Tuesday to check on the processing of this inquiry, and they keep telling me they are attempting to get clarification on it. I have a feeling they will be telling me it is not covered. My policy booklet is very vague, so I have asked them for a letter which explains their position on WLS. I have not gone to our HR department at work, mainly because I am not comfortable with the level of confidentiality that exists in our office. But, I will go to them soon if I don't get an answer directly from the insurance. Also, I have a possibility of picking up my husband's insurance as secondary. He just got it where he works, and it is Highmark Select Blue, which I think is an HMO. Anyone have any experience with them? Would it be worth it to sign on (if they will even accept me)? I don't know what it will cost yet. I'm sorry for the long post, but I'm beginning to feel a lot of frustration, and just want some support and to know that I'm handling this correctly. — Carlita (posted on December 17, 2002)
December 17, 2002
Carla, why have you not had the surgeon send in the request for approval?
I will have to say, working for an insurance company, I have
noticed.....(let me see, how I can put this)...A lack of 'training' in the
specifics of claim payment in the customer service area. There, that was
kinda nice. : ) The people that answer the phones usually have no idea
about plan specific information. It is their job to listen to us ask
questions, and complain, take notes and forward the information on to
someone that can respond/fix the issue. Your request is not a common one
and they may have not known who could take care of that situation.
~~translation......it got lost. At this point, your best course of action
is to have your appointment with the surgeon and have him send in the
request. As for the secondary insurance through your husband, see if you
can get a copy of the policy. Check to see if it is even covered and what
their COB rules are for secondary payment. It may not benefit you to have
a secondary, depending on how good of a policy your prime is and what their
coordination rules are.
— RebeccaP
December 17, 2002
There really should be anything vague. Either there is an exclusion for
treatment of morbid obesity in the exclusions section of your benefits
booklet or there isn't. If there isn't then that is your open door to
surgery. May be with a fight but the door is open.<p>My BC/BS
policy's exclusion section clearly indicates that treatment for weight loss
and obesity is excluded except Morbid Obesity and disease etiology. Open
Door! So the question is not whether I can have the surgery it is what
hoops will they make me jump thru and at 432 I don't jump too
good.<p>Once you know that it is not excluded (assuming your policy
is like mine) then call the insurance and give them the following procedure
code - CPT 43846 and tell them you are verifying coverage for this
procedure. They won't tell you how much they will pay but if you know the
amount the surgeon will bill for that code they must tell you if that will
be fully covered and if not fully covered how much is. Legally they must
give you this information regardless what they tell you. As a subscriber
you are entitled to know what your costs will be. They may ask for a
diagnosis code also which is 278.01 for morbid obesity. They may also tell
you that it must be pre-approved and it's only payable if medically
necessary, which is fine. Then ask them for their criteria for medical
necessity and make sure it is specific to this disease and surgery and not
their by-the-book spiel.<p>I know others have had trouble getting the
cost information but stand your ground. I called up and within a few
minutes to pull everything up I know that the $6000 my surgeon is expecting
they will cover that amount and more. I don;t know how much more but I
don;t care because as long as they get $6,000 it won't cost me anything for
their work.<p>As far as your husbands insurance I'd make sure I
checked it out thoroughly to see if it is covered etc. It might be worth
it and most likely if it's an "open enrollment time" then he can
add you with no issues and pre-existing won't apply. It's when you try and
add part way through the policy year that it's a problem. Good luck and if
you have any more questions I try and answer feel free to e-mail me. Chris
D.
— zoedogcbr
December 17, 2002
Sorry I can't type tonight! Should read: There really
<b>isn't</b> any reason it should be vague.....
— zoedogcbr
December 17, 2002
The procedure code I gave you is for open RNY. Sorry don't know any of the
others.
— zoedogcbr
December 17, 2002
Hello, I wanted to help you with your insurance problems. I have been in
the insurance field since 1985. I started with BCBS and have worked my way
up lol not to mention being a nurse too. :)
Ok, first of all, I would write a letter to the President of Claim
Operations of BCBS in your area. Explain to him/her that you have tried
numerous times since 10-02 with no response to get an answer. Let them know
your fighting mad and your tired of their stall tatics and you want an
answer within 30 day's or your sending a letter of complaint to your local
Insurance commissioner.
Second, I would hold off adding you to your husband's insurance, because
most policies have a waiting period for major elective surgeries. I would
hate to see you spend more money on more insurance if it isn't going to
help you.
Please know this. It is the end of the year and MOST insurance companies
are slowing down paying claims or approving surgeries for the end of the
year books. I know, it sounds mean doesn't it? But, I promise you it
happens and NO it isn't fair. That is the reason you need to fight like a
PMS'ing TIGER and grab BCBS where it hurts. I can bet you, you will get a
response. When you send the letter to the Director/President of operations
of claims. I would send it certified mail... That way you have proof of
BCBS receiving the letter. Also call ahead and ask The person's name you
need to send it to. They are not going to be happy to give you the name,
DONT GIVE UP ask for their manager. If that doesnt work go to your
Personnel manager at work ask for the name and phone # of your Insurance
Rep. call them. <they will give it to you teehee>Double whammy for
BCBS. Whew this is fun lol. If you want to talk to me feel free to email
me @ [email protected]
Best of luck to you,
Karen J WLS 11-13 down 36 lbs
— Karen J.
December 17, 2002
Ok I forgot one thing,,, actually the big thing. I didn't address you not
seeing your surgeon. Well, actually they probably are not going to give you
an approval without seeing your Dr.. Your Dr. will need to get the
approval. AFTER your visit!
So go see your Dr. lol then you might get a quick approval. If after you
see your Dr. and they are still stalling. then use the below information to
get it approved.
Karen J
— Karen J.
December 17, 2002
Thank you, Rebecca, Chris and Karen for your expertise. I wanted to
clarify a couple of things and tell you some good news, I hope! I have not
made the surgeon consult appt yet because their office had already asked
for pre-approval, or whatever you call it when you're just finding out if
the policy covers WLS. BC/BS told the surgeon's office that a benefit
exists under the Major Medical portion only, which means that I would have
to pay out-of-pocket expenses. I decided to get my own clarification,
since that didn't sound right to me. Most surgeries and hospital stays are
covered under the med/surg portion of the plan. Anyway, after I posted
this question yesterday, I called BC/BS again and asked to speak to the
supervisor who had made the request for clarification. I spoke with the
original customer service rep, and she apologized for the wait, telling me
they were waiting for their system "to update." She didn't
explan what that means, but told me she would be sending me a letter
explaining the benefits available. I should have this within a few days.
She outlined the coverage, and it looks like RNY will be fully covered.
She said the policy states that with a diagnosis of MO it is "not
ineligible" for coverage. I asked for their definition of MO, and she
said BMI of 35+, 100 lbs over ideal weight. If I get this letter, I'll
probably be putting it in a safe deposit box at the bank - it will seem
like gold to me!!! Anyway, thank you for your responses and suggestions.
I have printed them out and will refer back to them if I don't get the
letter. If I get it, I'll be making the consult appt with my surgeon.
Also, will update my profile to keep current. It's great to know there are
so many people willing to take the time to give their support here.
— Carlita
December 18, 2002
Carla: Sounds like things are promising. It appears your policy has the
same exclusion to the exclusion of treatment for weight loss, except in the
case of MO. Never thought you'd be happy to be MO, hey? Then again if we
weren't we would not need the surgery. A catch 22 I guess.<p>You
might want to start gathering PCP's notes and letter and other pertinent
doctors notes and tests to help support your case. Also I would check into
getting an appointment scheduled for your psych eval. Sometimes it can
take a long time to get in and they likely won't submit for approval
without it. The more you can provide them the fast the process will
go.<p>You made one statement that concerns me. You said that the
supervisor indicated the surgery was covered in full. Unless the surgeon,
hospital, anesthesiologist etc. etc. all have separate provider contract's
with your particular BC/BS policy you might get caught up in the UCR
(usual, customary and reasonable)game. Bc/BS would cover 100% of UCR but
if any of the providers bill above UCR then you would be liable for tha
balance. If they are providers that have contracted with your insurer then
they must write off anything above UCR and above their agreed upon
reimbursement. So just be careful when people say things are covered in
full. Buyer Beware! Good Luck and I hope everything goes smoothly from
now on.
— zoedogcbr
December 26, 2002
If your husband's insurance is an HMO and you plan on using them as
secondary, you must get authorization from them first in order for them to
cover it. You may want to check with his HMO first to see if that is
something they cover, then your out-of-pocket expenses are very minimal.
If you feel uncomfortable dealing with your HR dept, then contact your
insurance carrier and ask for the rep who handles your account. When you
contact your insurance carrier, make sure you get their name and you can
use them as a point of contact each time you call. Let them know you'll be
calling back again and asking for them each time.
— dolphins94
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