Question:
Has anyone been told Medicare and BC/BC does not do precertifications, or predertirmi

I have BC/BS of Alabama through Michigan from Ford Mo. Co.and also Medicare, they both tell me they do not do precertifications or prediterminations, My inc. co. says they do the surgery first and the decide if they will pay. My Dr. office says they will not do the surgery until approved. And BC/BS says that they will not be hearing from them even though they have received papers from the Dr.Has anyone experienced this??? it has been 2 1/2 weeks!!    — peaceangel58 (posted on August 1, 2000)

August 1, 2000
Hi Debra....I also have BC/BS of Michigan. And like you I was told they would decide if I qualified for payment AFTER I had the surgery. I didn't feel comfortable not knowing what my chances were of being approved so I went to my UAW Union Representative that handles our insurance complaints. She called the BC/BS office and talked to their rep that handles our Unions claims. My rep ended up sending all the paperwork to the BC/BS rep, the same package that the Dr would have sent. She reviewed it and said I was "unofficially" approved. Because of their new "policy", she wasn't able to give me a pre-approval number, so I went with her word. I am only two weeks post-op so I don't know what the outcome is yet, but having it unofficially approved was good enough for me as long as my union rep had been involved. Good luck on your journey......hope to see you on the "other side"! =-)
   — Marcella S.

August 1, 2000
YES! I had the same problem. My doc had BC/BS fax him the WLS Criteria as it was writtin in their policy ... that way he could determine if I qualified for the surgery based on their payment criteria. BC/BS Federal's criteria is 100 lbs over your ideal body weight and a BMI of at least 40. As long as you meet that critieria they will pay. BC/BS does still preauithorizes the hospital admission ... They pretty much told me that if they authorized the admission for the surgery, that was a pretty good indication that they would pay for the surgery. My doc had the same feelings as yours at first ... he didn't want to schedule me without payment guarantee ... but with the two things I described above, I have a surgery date of November 29th!! Good Luck!!
   — Donna H.

August 1, 2000
Dr. Gleysteen at UAB takes Medicare. Please know he is already booked through 2001, though. I understand Drs. Stahl and Shearer are MUCH quicker to get in, but don't know if they accept Medicare. Best wishs.
   — [Deactivated Member]

August 2, 2000
I have heard some say that BCBS no longer requires pre-authorization but I can tell you that I have BCBS PPO of Michigan and they required pre-authorization for wls and they also denied me just last week for the surgery. They spelled it out loud and clear that if I had the surgery I would be completly responsible for the entire bill myself.
   — Sheila B.

August 2, 2000
The BCBS PPO of Michigan policy that I am insured under has put me thru 14 weeks of hell conveniently misplacing documents, refusing to accept faxes, refusing to even verify they had received my paperwork until I involved the insurance commissioner and after that they amazingly confirmed they had my documents within 24 hrs. WLS is NOT excluded under my policy and when you call the 800 number and give them the cpt code for the distal bypass, they say it is a covered benefit under my plan as long as the diagnosis is that of MORBID obesity and you provide proof of medical necessity. I met those requirements but they are saying they are denying any distal bypass as "investigational". I don't understand how they can do that if they still claim that the code for the distal bypass is an approvable code on my policy! I am appealing and will sue them if they continue to deny me the surgery I need. I have been fortunate to have some others with BCBS of Michigan e-mail me so I can prove that BCBS does permit distal bypasses...even if we do have different employers and plans it is worth a try. I am wishing you much better luck than I have had!
   — Sheila B.

April 28, 2004
Medicare does not precertify the surgery. You have the surgery first and then they let you know if they will pay .I had to sign a waiver that if Medicare wuldn't pay for the surgery, I would pay for it. I signed, because I have no choice.
   — sandra A.