Question:
NO pre- authorization needed, EVER HEAR OF THAT???
I see lots of questions about insurance but my doctor does not take my Blue Cross Blue Shield PPO so I pay up front but the doctor's assistant said the company usually covers most of it. And she said the hospital is in my plan. I doubted this so she gave me the code for surgery and the codes for the co-morbids. I called the insurance company and gave the rep my id #s plus all the codes. Then the rep came back on the line and said it is a covered benefit if medically required because of a BMI of 40 (MO) and a co-morbid. She said that is an approved hospital so I don't have to have a pre approval to go to that hospital. I did not want to talk them out of it and start an arguement so I said thank you. AM I MISSING SOMETHING??? — Grace M. (posted on April 15, 2002)
April 15, 2002
Yes, Medica has gone to a "no review" policy. I think some
insurances are catching on finally. I would however make sure you have
everything in writing before having surgery.
Best of Luck!
— ZZ S.
April 15, 2002
I have federal BC/BS. I used a PPO hospital and it cost me a $100 fee. My
surgeon was PPO so my share was only $285, his assistant wasn't so I paid
1/4th. My surgeon tried to get BC/BS to preauthorize but they said they
don't. They would pay if it's medically necessary. I was worried but they
paid. My BMI was only 42 with no comorbidities.
— Michelle F.
April 15, 2002
What state do you live in and where do I apply for that insurance? I've
never heard of that but it sounds to good to be true. And you know what
that means; It just might be. There are things you'll want to take a look
at. My ins. company (Ochsner- Louisiana) has something called a pre
exsisting claus. Most companies have the same thing. What this means is if
you have not had your coverage for a full year but have had that condition
before you got that ins. then they will not cover it till you make a full
year of coverage. So if you have had your ins. for a year then that's fine.
But here is where they like to get you. If you have not been covered for a
year they may still cover the surgery, (no questions asked) and then refuse
to pay for it after you've had it. That makes things a little complicated.
To me it sounds like this may happen because they can come back and refuse
to pay saying that you did not have approval before hand. I'm not saying
that this will happen but it's something to be careful of. Look through
your booklet and make sure there are no loop holes. Get the name of the
person you spoke to on the phone and if you can, tape the conversation
(tell them you are taping the conversation because this is illegal unless
they know you are taping them). Make sure to protect yourself. You don't
want to put your family's well being on the line before you are ready to
take on a $20,000 debt. Best of luck to you and I hope that you really do
have such a great ins company.
— Sarah K.
April 15, 2002
Sounds like me- I have BCBS PPO and my Dr and hospital were
prefered providers. I was told that it was covered, but that
they couldn't tell me to what dollar amount- so I had to just
hope it was going to be ok. Well, then I thought about it.
IF it is a PPO hospital- that means the insurance and hospital
have an agreement on what is reasonable and customary and the
patient shouldn't have to pay anything. For my policy, if
I go to a non PPO, then I will be responsible for 10% of his
fees and BCBS picks up the rest. For your own sake- I would call back and
ask again and get the reps name AND get it in writing. Because
people do make mistakes, and if she did, you could pay.
— M B.
April 15, 2002
I also have BC/BS ppo,and my insurance covers 100% if it is considered a
medical necessity.Even though my insurance covered this type of surgery, I
still had to be pre-approved to see if I fell in the category of it being a
medical necessity.I was approved in 3 1/2 weeks,but my surgery was
scheduled 3 months later.{the Doctor is really booked up} I hope this
helps. Lora B
— Lora B.
April 15, 2002
I have BCBS of AL, PPO, and I needed no referral for either for my surgeon
or the hospital he uses, but of course, my WLS did have to go through the
approval process. I think that with most PPO's you don't need prior
authorization to see another doc, a specialist, etc. Not sure if I answered
your question, bur I tried! 8-) Donna in AL
— Donna S. C.
April 16, 2002
I have BC/BS PPO of GA. I have a 80/20 plan where my out of pocket maximum
is no more than $2,000.00 with a $500.00 deductible. I am still waiting for
approval wich was submitted on April 5th. They said it takes up to 14 days
for a decision. They told me that for this type of procedure you have to
get "prior approval" which is different than
"pre-certification" even though they sound the same to me. Both
my surgeon and the hospital are in-network. My policy does have an
exclusion for treatments of obesity but everyone I have talked to say that
as long as it doesn't exclude "morbid obesity" then I should
have a chance, especially if its medically necessary.
— mikawill
April 16, 2002
Well this "no preathorization needed" doesn't mean that they will
cover your surgery. BC/BS sometimes takes this approach, and then after you
have the surgery they will deny the claim as not being medically necessary.
I almost got caught in this situation. You, and most doctors, will still
want a pre-determination, which is different from pre-authorization.
Pre-determination means that yes they will cover it. I would definately
talk to both your Dr's insurance people and your insurance co. to get in
writing that you will be covered, or you could end up with a big bill.
— Dell H.
April 11, 2003
I have BC/BS Community Blue PPO of Michigan. I just got off the phone with
one of the lady's at the surgeon's office and she re-affirmed that I do not
have to worry about getting an approval. She said that with my comorbs. my
bmi and everything else that this is medically necessary and they will
cover it. She is going to call my insurance co next week though and talk to
someone that deals with in patient and discuss it before I actually go in
for pre-op tests. But basically she told me not to worry about anything and
that everything is going to go ahead as planned! God I hope she's right!
— Sarah G.
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