This Sucks!

[Back~To~Amy 307]

I called my insurance company (Anthem BCBS) yesteday and was told I had coverage for LB surgery. The guy told me that once my deductible and copays are met (which they will be because of another surgery), the LB would be covered at 100% by them and I'd owe nothing.

Well, I called back today because I was trying to get additional information and now am being told they will only pay 50% of it and it isn't subject to my deductible and out of pocket maximum. I told the girl of my conversation yesterday and she is going to check further and call me back but she is pretty sure I was given wrong information yesterday. If I have to pay half, there is no way I can afford this surgery now with what I'm going to have to pay out of pocket for my other surgery. Yeah, I might could finanace, but I doubt I could afford that monthly payment so that would nix that!

Ugh!

[NWgirl 574]

I have anthem BCBS and it is definitely covered on my plan.

Anything out of network is billed at 50% with no cap. Anything in network is 20% up to your OOP. It is also required that the surgery place be a center of excellence.

Call Anthem Bariatrics and transplant line at 1-800-824-0581 if you have not already done so. You will need to leave a message for Angela with ID #, full name, and birthdate. They will assign you to a case manager and will be able to tell you more. The people in regular customer service are not the ones you should be speaking to.

Good luck!

[Back~To~Amy 307]

Thanks Steph. I actually left Angie a message earlier and am waiting for her to call back. I started googling that center for excellence stuff and it looked like it is only hospitals. My potentional surgeon uses an outpatient surgery center so I called customer service back to see if they had referred me to the right place. Somehow during that call my benefits came up. I'm glad yours is covered at 80/20. However, I think that has to do with your employer and not the insurance company itself. Employers have a lot of say so on the coverage. Anyway, the girl with Customer Service was super nice and is going to get with the lady who manages my companies plan and get clarification. I will discuss with Angela too when she calls back. Thanks for the advice.

[twi 40]

They did something like this to but they told my dr that they didnt cover it at all. I had called and asked them to send me all requirement pror to this so I had 28 pages proving that they did they cover 100percent since I had met all out of picket. Call again get the 28 pages and keep for people. Different people say different things get all their name and employee number. Good luck

[SageTracey 608]

Damn, that is so frustrating! Makes you wish you had recorded the first conversation so you could play it back to them! Good luck

[Back~To~Amy 307]

Actually, the call was recorded and I have the reference number so the call can be easily found and listened to. The problem is before a rep comes on the line there is a recording that says " this is not a guarantee of payment". The rep I talked to today did say she will have the supervisor over my account listen to it, but I don't think it will matter with that disclaimer.

[NWgirl 574]

Actually, the call was recorded and I have the reference number so the call can be easily found and listened to. The problem is before a rep comes on the line there is a recording that says " this is not a guarantee of payment". The rep I talked to today did say she will have the supervisor over my account listen to it, but I don't think it will matter with that disclaimer.

Unfortunately, you're right. I have read of times where insurance reps have told people they are covered and then they go through the whole process and amass $$$$'s in bills, only to get a denial letter saying it is not covered at all. I have also heard (and experienced myself at one point with a different insurance) of the insurance coordinator's for the surgery centers not verifying and only ASSUMING the surgery is covered based on what they know about the certain plan, and then finding it is not part of that plan.

There really should be a way to take legal action when they do this.

[jen_1381 446]

The WLS Coordinator told us during the seminar that if you call and talk to Member Services three times in one day, you will almost always get three different answers. I was super excited when I called once and they told me it was covered completely once I hit my deductible. She warned that the info might not be entirely accurate. Also, the people that the WLS Coordinators call to verify benefits and the people that customers call to verify are seperate people, and the two units typically have no communication between each other (ie: if they document the patient calling and telling them they cover it, they won't see that when the WLS Coord. calls). The bottom line is - get it in writing. My WLS Coordinator got the 28 page print-out outlining all of the bariatric benefits and said that if they change the policy between now and surgery time, she can refer back to the dated policy she has in hand. Good luck to you!!

[Back~To~Amy 307]

Thanks Steph and Jen. You both make such true statements. I haven't given up yet. I just hope if I go forward, the doctor will have more than just verbal approval.

[NWgirl 574]

Thanks Steph and Jen. You both make such true statements. I haven't given up yet. I just hope if I go forward, the doctor will have more than just verbal approval.

When someone calls you back from the Bariatrics line, they will ask you a few questions about who your surgeon is and where it will be. They will then send out a bariatric benefit summary.

[Back~To~Amy 307]

When someone calls you back from the Bariatrics line' date=' they will ask you a few questions about who your surgeon is and where it will be. They will then send out a bariatric benefit summary.[/quote']

Good to know. I hope they call tomorrow. Otherwise, I have to wait through the weekend. Patience is not my strong point!

[Back~To~Amy 307]

Well, Angela called me from the bariatrics line but won't give me coverage. She said I have to look at the Blue Care Centers list she is mailing me, pick a surgeon who works out of one of those facilites, go to a seminar, submit proof to her then she will mail me the benefits. I tried to ask her what my benefits would be because I will use an approved facility. She said "I'm not telling you that. You have to go through the process and then they will be mailed to you".

It's a waste of my time to go to a seminar if I don't have good coverage! Plus, it will get my hopes up for nothing! Ugh! I hate their procedures!!

[Cocoabean 430]

Can you see your coverage online? I have BCBS California Acess H M O. I can enter my member # online and log in to see exactly what my coverages are.

http://www.anthem.com/wps/portal/ca/member?content_path=member/f1/s0/t0/pw_a103465.htm&label=Member%20Home

That is the portal for Anthem BCBS, it has a link to login or register. Take a look at what your coverage is, exactly. It may be different if you use in-network vs. out-of-network. It also appears that your surgeon must have privileges at a Center of Excellence.

http://www.anthem.com/medicalpolicies/policies/mp_pw_a053317.htm

That is Anthem's Medical Policy for bariatric surgery.

Best wishes!

[Back~To~Amy 307]

I can see very limited coverage on line. Apparently, the lack of insurance coverage is because my employer. They are basically in charge of setting what the coverage is.

[waitingpatiently 250]

Hmmmm. Being told what benefits and coverage you have seems to be a right to know. I would call back and demand to speak to her supervisor. then ask under what rule do they have the right to with hold information from you considering its your policy that you help pay for. You may also want to speak with human resources, the insurance coordinator may know. You may also want to call the center that is in your network, and speak to their insurance person. I know that my doctors surgery coordinator already knew what I was required to do for approval and how much I would be exspected to pay....without me telling her anything.