TracyinKS

OK.... now I'm on the trail of emailing the supervisor in the Managed Tier department at BCBS SC, and copying in the insurance coordinator at the surgeons office... they should approve me just to get RID of me! LOL Good Morning Cindy: This is Tracy ID # xoxoxoxo and I talked to you a couple days ago about Pre-Certification for the Lap Band, Billing CODE # 43770 on our CDHP plan. I really appreciated you getting back to me so quickly. The insurance coordinator at my doctor’s office wanted me to ask you what exactly is thePREDETERMINATION process. She said I should do this before my appointment on Monday, and so here I am asking you. I went and looked up the policy on the http://www.myinsurancemanger.com/kc, but didn’t really see anything too different that what is stated on our SPD. I have a BMI of 43.6.. which means that I’m 5’5” and weigh in at a whopping 263.8……… I have lost the same 80 lbs 4 times in my adult life, but I’ve never been able to maintain it, that is why I want the Band… the band is a tool that will help me to once again achieve the loss but also aid in maintaining it. I would appreciate it if you could look up our policy and then let me know what exactly the Predetermination Process is. I have $$$$ in my HRA account, and my out of pocket max loaded on my FSA card. Thanks for all your help. Tracy

this is hot off my email... Dear Tracy, I do not work on Fridays; I just happened to stop by for a moment this morning and checked my email. If you would like to call me on Tuesday I would be happy to talk to about this. It sounds like you have done your research so I don’t know how much more help I can be until you come in and see Dr. Malley and I can get your Insurance information to call and talk to them myself. One thing that may be causing the confusion is that you keep saying you don’t need a pre-cert, what we send in is not a pre-cert, we call it a pre-determination and it is a completely different process. A predetermination is actually a review of coverage determination, based on the medical information that is submitted by the surgeon. If you want more information on this before your appointment, you can call your insurance company back. This time I would give them the specific code for the Lap Band 43770 and ask them the “predetermination” process for that and any and all criteria that there is. I could not find the bariatric policy from the link that you gave me, so I can’t see how it reads. If under your coverage it says that morbid obesity is covered if “medically necessary”, right there it is saying that it needs to go under a review for an approval. I truly think that the misunderstanding is with the word “pre-cert”. For all of our surgeries, we never obtain a pre-cert number, we either get an approval or denial based on the review of coverage. I would be happy to discuss this further with you, if you want to give me a call back on Tues. I hope that this helps and have a great weekend. Sincerely, Rachel H.

Oh and this was my email back to the surgeons office this morning. Hello Rachel, I just got this email today (Friday morning). I will give you a call later this morning. Thanks. I think how this will work is that technically, I don’t have to have a pre-cert, but to get speedy payment on my claims. I am going to have to prove medical necessity….. I think this may be a loophole in our plan and they didn’t realize would happen because our enrolment books clearly state for those with the CDHP, *NO pre-certs or copays on ANY service* I’ve already got confirmation of this from 2 supervisors at BCBS. (I’m the HR person for my company), and I actually had to GO to Columbia SC last summer for a train the trainer meeting where I toured their headquarters/call center and met all these same people…. After they went back and pulled our policy for the CDHP both came back with the NO PRE-Certs allowance. (It is why I chose the CDHP over our PPO plan) I am committed to getting this pushed through, and I have all their names and numbers I’ve attached their Morbid Obesity policy from their website. www.myinsurancemanager.com/kc Policy, Surgery, Morbid Obesity WLS Thanks for getting back to me, and all your help Tracy

LOL! thanks Donna.... I did get kind of a depressing email back from the insurance coordinator at the surgeons office..... but this tells me that she has never worked with my kind of plan, so I'll have to educate her too..... I'm going to spit nails if I have to do a 6 month diet plan.... but little does she know how I am when I'm fired up about something..... Just over the phone I had 2 supervisors backpeddling... (See I really think this is a loop hole, that wasn't closed up, because my company JUST switched to BCBS, and they REALLY put on the dog and pony show for us to join up) but here is her letter......... (I'm taking my enrolment book with me to show her), and all the names and numbers of people I've talked to and WE will call them after my consult.... so I might just have some kind of answer on Monday afternoon. Dear Tracy, Please give me a call on Thursday if possible so we can go over some of these things. I have never heard of a bariatric surgery not needing pre-cert but this could be something different. The reason I say that, is in order to use a bariatric benefit your insurance has review your history to see if this surgery is medically necessary for you. If they didn’t have to review it then people who were 20 pounds over weight could have the surgery and their insurance would pay for it. Does that make since? Insurance is a totally different ball game when it comes to bariatric benefits. What I would have to do is after your appointment I will call your insurance company and talk to them. Until then I couldn’t tell you much. But just to be completely honest with you most likely your insurance has criteria they will want to see prior to approving you for a bariatric surgery and if they want for example a six month diet with monthly notes from your doctor then you would have to complete that before they would approve you for surgery. Unfortunately, letters from your doctors stating your need for surgery will not get you past having to meet these criteria. We have patients that there life is at risk if they don’t loss weight and we have letters from there doctors stating just that, and they will not approve them until they meet the same criteria that all other members have to meet. Again, your policy could be different but I just wanted to tell you that the chances our slim. Please call me on Thursday if you have any other questions. Sincerely, Rachel H.

Thanks! I printed it out and put it with my other documentation!

Do a search for Dr. Kuri and you will find lots of info...... and CONGRATS on your surgery! HOW EXCITING!

Congrats on your surgery FancyMan! I would listen to the fine experienced ladies above and get out your food processor

Congrats on becoming a bandster! I can't wait to be able to say that... Keep us posted!

CONGRATS!!!!!!!!!!!!!!!!!!!

Sharon: Yes, that is the one I am attending....... I'm excited. My dh is attending with me, because he really has no clue what it all entails. I am praying that my insurance journey goes smoothly because I would really hope to be banded late January or Early Feb.... See you tomorrow.

Welcome Ashley! Look forward to your progress reports.

welcome to the boards

exciting!!!!!! I go to mine on Saturday..... I am so excited

wonderful news!!!!

bumping for an update

Congrats! so when do you go to a seminar?

Great Letter!!!!!!!!!!

Re-Read Kats response! I think she hits it right on the money! Man oh man am I glad I found this board before my surgery!

CONGRATS Rabbitfancy....... I can't wait to hear about your progress!

CONGRATS and post when you feel like it! Do you have all your stuff ready???? GASX strips, liquid Tylenol, broth, SF popsicles?

pplqueen: thanks for sharing the pics.. YOU LOOK GREAT..... as for the subject of this thread.... We ALL have food issues... and yes I think that some soul searching is a much needed exercise. This is a tool, and one that isn't going away once implanted.... I think you must be willing to accept the changes it requires, and come to grips that you will be losing your best friend "food" (it is something I am working on internally myself) Just like my daily ritual of drinking OVER a pot of coffee... a ton of diet dr pepper...... all things that have to change once I have the band.

WOW!!! did it have anything to do with your hernia? I hope the swelling goes down, keep us posted.

CONGRATS on the approval, the date and a NEW YOU in 2007!!!!!! How exciting

YEAH TAMMY!!!!!!!!!!!! Cant wait to hear about your seminar! Mine is THIS SATURDAY and my consult with the doc is MONDAY the 8th..........

I have BC/BS of SC, and I am expecting on the high side my cost to be around $3000. BUT I have an HRA plan (not an HMO or PPO) My plan is where I have a pool of money $1125 and if I use that I have a bridge (fancy word for deductible) of another $1125, then it goes to 80/20 plan. SOOOOOOOO what I did was put money in a Flex Spending Account to make up for my bridge and the extra...... this way I will have it all paid for with pre-tax money and paid for in a year.......... and if for some reason this flops..... everyone is getting a giftbasket with OTC stuff for christmas next year! LOL Please keep us posted on your progress........ it is how we learn