Question:
FEDERAL BCBS PPO Insurance

Would like to hear from post-op Open RNYs who have this insurance with BMI of 40-41, no majoR co-morbS except joint pain (back/legs/knees/ankles). Any problems getting insurance to pay? My doctor requires I pay up front half of cost because FEDERAL BCBS PPO won't pre-certify the surgery. I meet their requirements so they say. Please let me hear from you...am worried they won't pay. Am scheduled 12-6-02 for Open RNY.    — Debra L. H. (posted on November 16, 2002)

November 15, 2002
I had the same starting BMI and also have BCBS Federal plan. They paid the bills with no questions asked.
   — Kristen L.

November 15, 2002
I have the same insurance, and they paid for all but about $200.00. I had a BMI of 43. Who is your doctor? We have a support group online, and in person if you would like to talk to others in Oklahoma who had the RNY, also there are several with BC/BS federal PPO. One self paid because her Dr. made her because of her insurance and she filled with BC?BS and they are paying her back. But my DR did not require me to pre pay anything. E-mail me if you have any more questions.PS: They also payed for my TT and I am researching getting my breast reconstructed to, the book says they will pay for reconstructive surgery if it is needed due to a surgery, (and a few other reasons)but we fit into that one after RNY. You have to have documentation of trouble for them to cover reconstructive surgery, but they are wonderfull insurance!!!
   — nkoehler88

November 16, 2002
I had Federal BCBS at the time of my surgery and they covered it all except for a $100. Is your surgeon in network? My suggestion, look on the website or in your book and find a bariatric surgeon who is in network. I had my surgery at Bariatric Treatment Centers in Belividere, Illinois, but I know all BTC doctors are in network. I am sure there will be one in OK too. Also, you might want to find a surgeon who is familiar with your insurance, because it really shouldn't be necessary to pay up front. I believe they don't pre-certify because they think if it is really necessary you will do it without the guarantee. I think it is a way to scare some people off. Just know that as long as you are 100 pounds overweight and over the age of 18, they WILL pay for it. Call BCBS, they will talk to you about it. I did and they assured me they had never seen anyone who meet the above requirements who didn't get the surgery payed for. If you need any help, please feel free to contact me. I know what you are going through. Good Luck!
   — nchaudoin

November 16, 2002
Thank you to everyone who replied. Yes, my doctor is in the Network of doctors that BCBS Federal covers...so hopefully, you are correct in saying that maybe it's a scare tactic. I do meet the requirements. I'm 100 pounds over with a BMI of 41. It's just a LOT of money - even though I know it will be worth every penny if I end up self-paying. :-)
   — Debra L. H.

November 16, 2002
OK, this is strange, but I also have BCBS/Federal and they did pre-certify my surgery in May 2002. At least, they gave me a letter saying they'd authorized the surgery, in advance. My surgeon was also a participating provider in the BCBS/Federal plan, which is a separate issue from pre-certification. If your surgeon is a participating provider, then theoretically, he's agreed to accept what BCBS pays (except for the deductibles you're responsible for under your contract). (My surgeon apparently didn't agree to that, and he and BCBS have since gone their separate ways.) Anyway -- if your doc is not a participating provider, he accepts whatever they pay him, then comes to you for the difference, OR, he comes to you for the whole thing, and you go back to BCBS to get reimbursement for part, but either way, it costs you more out of pocket than if your surgeon was a BCBS participating provider. Clear as mud? Don't insurance companies drive you nuts? :D Absent a guarantee from SOMEBODY, I'd operate on the assumption that you could well be stuck paying for the difference until you can really find out what the scoop is with this doc and insurance company, or switch to another doc whose relationship with your insurance company is a bit clearer. Just my 2c!
   — Suzy C.

November 17, 2002
I also have Federal BCBS PPO. I had Open RNY on 9-10-02. Had no trouble getting approval. Just needed to submit paperwork they required. BMI 41 and NO co-morbites. They paid all but $100.
   — Mimi R.

November 17, 2002
I have BCBS PPO (Federal) and had surgery 7/5/02. They just paid the final bill (anesthesia docs) last week. They paid all of the hospital bill except $100 co-pay. They grossly UNDERpaid the surgeon. I had LAP and they would only pay the OPEN fee. He charged $10,000 and I had to pay the 10% copay before surgery. So, I paid the hospital $100, the surgeon $1,000 and the anesthesia docs $185.00 (my 10% copay). There were, of course, other bills for blood tests, pre-surgery tests, etc., but all were paid with me owing either the $15 visit fee or the 10% copay. I did have to call them on almost every bill as most were initially denied. I didn't have to formally appeal any of them, they just resubmitted and all were usually paid the first time they were resubmitted. So they do pay but you need to keep up with it and make sure things that should get paid do get paid.
   — jutymo