Post-Surgery Surprise --Federal BCBS Copay TIMES TEN

[abraxasbear 16]

I've had a terrible time with Federal Employees Blue Cross Blue Shield. At first, my pre-authorization paperwork had to be resubmitted after it was "lost." Then they pre-authorized the surgery within a day. Unfortunately, they didn't bother to tell me or my surgeon's office that you have to get TWO pre-approvals, one from the office that handles the surgeon's professional fees, and another from the office that handles the facility (hospital) fees. To make matters worse, these two offices don't share information, so the office handling the hospital charges ended up sending me their refusal to process $37,000 worth of hospital charges, because they had no records to support the procedure and it wasn't pre-authorized by them.

After multiple calls, I was able to get the second office to retroactively authorize my surgery. I expected to be charged a copay of $150 for my surgery and overnight hospital stay, since my surgeon requires all his lap band patients to stay in the hospital overnight. Imagine my surprise when this weekend I received a new explanation of benefits, indicating that my share of the bill was $1,496.72. More phone calls ensued, of course. I found out from the insurance claims office that the additional charges were due to my surgeon's office reporting the surgery as OUTPATIENT, rather than inpatient. They said all I needed to do was have the surgeon's office correct the medical record, and the billing department could resubmit a corrected claim.

I called the surgeon's office today, only to learn that they ALWAYS report lap band surgery as outpatient, and they justify this by getting you out of the hospital in less than 24 hours, even though it's overnight. (Mind you, I went into the operating room at 7:30 a.m., and was discharged the next day at about 9:30 a.m., so that's not under 24 hours!). The surgeon's office refuses to make the necessary correction, and so I'm stuck with the larger out-of-pocket bill. I wish I'd known this BEFORE surgery, so I could have REFUSED the overnight stay.

In any case, BE WARNED that what you THINK you'll be paying out of pocket could be very different from what you actually are charged---in my case, literally TEN TIMES the expected out-of-pocket!

[Amanda1982 142]

WOW I'm so sorry that happend to you. I've put aside the 2,000 that I'm supposed to pay out of pocket and nothing more. I would be devastated if I got a bill like that.

[StacyS 2]

I also have BCBS Federal..... I was aware of the Pre-Authorization but like you said, no one from the insurance company has said anything about a second pre-authorization letter needed from the facility. How would I obtain that?? Through the hospital where I'm having the surgery??

[StacyS 2]

I just called BCBS and they said I only need ONE pre-authorization, which would cover both the surgeon fees as well as the facility's fees..... OMG, I just hope they are correct and I dont get in a situation like this one. At least you were able to get the $37K charges resolved w/out it coming out of your pocket.

[abraxasbear 16]

I just called BCBS and they said I only need ONE pre-authorization, which would cover both the surgeon fees as well as the facility's fees..... OMG, I just hope they are correct and I dont get in a situation like this one. At least you were able to get the $37K charges resolved w/out it coming out of your pocket.

Stacy, I think the "two offices" thing differs between the states where the claim is processed. Mine was in Washington State, and apparently the split only is done for claims arising out of the Seattle metro area.

[cheryl2586 3,053]

Sorry for all your trouble but I can tell you that working in surgery that your time in the hospital starts from the time you go to the floor not from the time your surgery starts. That is not counted in that time so you figure 1 hour in surgery and 1 hour in pacu would leave you at less that 23 hours as an inpatient. They dont count the time before,during and in pacu because you are not admitted til you get to your room.

[StacyS 2]

What is Pacu?? So, if I understand you correctly, the time starts when you are admitted and in a bed prepping for surgery- then it stops during surgery and in recovery- then starts again when you get into a room??

[Grider 92]

I've had a terrible time with Federal Employees Blue Cross Blue Shield. At first, my pre-authorization paperwork had to be resubmitted after it was "lost." Then they pre-authorized the surgery within a day. Unfortunately, they didn't bother to tell me or my surgeon's office that you have to get TWO pre-approvals, one from the office that handles the surgeon's professional fees, and another from the office that handles the facility (hospital) fees. To make matters worse, these two offices don't share information, so the office handling the hospital charges ended up sending me their refusal to process $37,000 worth of hospital charges, because they had no records to support the procedure and it wasn't pre-authorized by them.

After multiple calls, I was able to get the second office to retroactively authorize my surgery. I expected to be charged a copay of $150 for my surgery and overnight hospital stay, since my surgeon requires all his lap band patients to stay in the hospital overnight. Imagine my surprise when this weekend I received a new explanation of benefits, indicating that my share of the bill was $1,496.72. More phone calls ensued, of course. I found out from the insurance claims office that the additional charges were due to my surgeon's office reporting the surgery as OUTPATIENT, rather than inpatient. They said all I needed to do was have the surgeon's office correct the medical record, and the billing department could resubmit a corrected claim.

I called the surgeon's office today, only to learn that they ALWAYS report lap band surgery as outpatient, and they justify this by getting you out of the hospital in less than 24 hours, even though it's overnight. (Mind you, I went into the operating room at 7:30 a.m., and was discharged the next day at about 9:30 a.m., so that's not under 24 hours!). The surgeon's office refuses to make the necessary correction, and so I'm stuck with the larger out-of-pocket bill. I wish I'd known this BEFORE surgery, so I could have REFUSED the overnight stay.

In any case, BE WARNED that what you THINK you'll be paying out of pocket could be very different from what you actually are charged---in my case, literally TEN TIMES the expected out-of-pocket!

[Grider 92]

WOW I have been asking these questions for 3 days of all the forums etc. This kinda news would devestate me financially,, (govt employee)- lol, no I am just a GS-7 so seriously. I think I am going to be the biggest pain in the butt with asking 1000 question of every one, you would think by now everybody have this down to a science! I have fepblue florida, just starting -the INS book let is NOT very imformatived NO one here said anything about the 3 months of medical wight loss program, t the bloggers all say 6 months?

I have FEPblue florida, just starting but when I called, the gal started reading out of the booklet,,, I can do that!! I wanted clarification. One good thing is my surgeons office is by a military base, so I think they have some prior knowledge of how to work with FEPBLUE. GOOD luck in sorting this all out, hope you lose weight over it! but NOT your health and peace of mind.