blue cross blue shield

[maltomeel 0]

Airwayman...funny thing, my Dr's insurance "girl" is Kim and his nurse is Dawn! Odd!

My pulmonologist decided to snail mail, not fax my results to my surgeon...WTF??? I thought we'd be submitting today

Waiting......

Jill in NY

[airwayman 2]

Airwayman...funny thing, my Dr's insurance "girl" is Kim and his nurse is Dawn! Odd!

My pulmonologist decided to snail mail, not fax my results to my surgeon...WTF??? I thought we'd be submitting today

Waiting......Jill in NY

So, your Dr's gals are Kim and Dawn? Weird, I'm in NC and you're in NY? Reminds me of the joke about the two guys who just happen to be sitting next to each other in a bar in Miami. They get to talking and find out they're both from Chicago, both live on the South side, both live at 314 Elm street and are BOTH married to a woman named Elvira. One says "Well how about that!!! We's husband-in-laws!!!"

As regards your pulmonologist's lack of concern, that reminds me of the time we were having a house built. The shutters came prepainted and in boxes so we didn't open them to see what they looked like. Later in the day I went out to the project and all the shutters on the top of the house were black and the ones on the bottom were brown....obviously there was a mix up in delivery The foreman drove up and I was mad!! I asked him why ANYONE would put those shutters on when they knew they were the wrong color!!! He calmly looked at me and said "hey, it ain't their house." The shutters were fixed and life goes on but I never forgot that lesson....no one really cares as much about you as you do. You are your own Captain. Steer your own ship, don't let others push you off course. I have the upmost respect for doctors and nurses but, "hey, it ain't their body." Good luck, my friend. JB

[singdeborah 0]

Weird, paying for the port only. I know last year BCBS FEP said that they would pay for surgery and not anything else, but now they are paying. I waited two years for them to pay. I know it's not the same policy as you but you have my sympathy. We have to pay 10% whatever that will be. I'm just waiting now as I have mononucleosis and the physical therapist said I have to get my strength back or she won't approve me for surgery. I have passed everything else but that.

[maltomeel 0]

Ain't it the truth.

I called Empire BCBS about 10 weeks ago when I began this process and asked them to kindly mail me their bariatic WLS requirements. They told me that I must submit a request in writing, via mail. I did and until TODAY had not received a thing. In between, I called to see when I can expect a response. The rep had NO clue and said "we don't do that". Hummm..okay, then how do I find out the requirements?? She put me on hold for 12 minutes and then said she would transfer me to a case manager....but that it was almost quittin' time and they may not pick up! LOL. I admired her honesty.

A case worker did pick up and discussed some details with me but was not comfortable with our conversation as I was the PATIENT and not the surgeon's office. I was as calm and kind as could be and explained that I wanted to meet all BCBS requirements, which may include (as I'd heard) a 6 month supervised diet...and if that were the case, I'd like to make sure I got started sooner than later so can I PLEASE have the requirements. She said she wold read them to me. Not ONCE was a 6 month diet requirement mentioned. I kindly thanked her and noted her name, date & time of call.

4 weeks later I get the documents! The cover letter had some details of my coversation with the case worker (Judy) as well as a plethora of info on bariatric surgery and coverage. If I had a scanner I get it up for you all....but that will have to wait until work on Monday. Oddly, it was signed my a gentleman named Walter(not Judy) whatever.....

According to the documents, I meet the requirements and have all my paperwork in order. Now, to get the surgeon's office to get it to BCBS and in "the system"........

Please feel free to e-mail me at maltomeel@optonline.net if you have Empire BCBS of NY. I will provide any info I can to make this whole thing easier for all.

Jill in NY

In for the long haul

[airwayman 2]

Ain't it the truth.

I called Empire BCBS about 10 weeks ago when I began this process and asked them to kindly mail me their bariatic WLS requirements.

They told me that I must submit a request in writing, via mail. I did and until TODAY had not received a thing. In between, I called to see when I can expect a response. The rep had NO clue and said "we don't do that". Hummm..okay, then how do I find out the requirements??

A case worker did pick up and discussed some details with me but was not comfortable with our conversation as I was the PATIENT and not the surgeon's office. She said she wold read them to me.

4 weeks later I get the documents!

This is absolutely ridiculous!! This is no way to treat someone who is trying to go by the rules and learn what must be done to qualify for an approved medical procedure. If I were you, I'd call the NY state insurance commission and complain. In contrast, I called BCBS NC because I had heard a rumor that they were on the cusp of changing their policy for gastric banding. The first person I spoke with was a complete idiot. She was more than that but idiot will do on this forum. I quickly begged out, hung up and called back later. The second lady was fabulous. She said she had heard there was a change in the policy but was unfamiliar so, together, online, she walked me through the clicks to get to the .pdf file titled BCBS of North Carolina Corporate Medical Policy for Surgery for Morbid Obesity. Together, we read the changes, which moved gastric banding from "investigational" (read not covered) to the approved procedure area. The policy also states the requirements and the exclusions for gastric banding surgery. I was able to print this out and in ten minutes I had the approved procedure in my fat little hand. I have now fullfilled all the requirements and am waiting for the Dr's office to call with ins. approval. They said it normally takes up to two weeks. Some have been coming back approved in one week or less. In your case, I recommend you work through your Dr's. insurance person. He surely has one or more people who deal with Empire BCBS all the time and know the ropes. Good luck, my friend. JB

[maltomeel 0]

We can only hope. Thanks for your feedback. Kim at Dr. Mayer's office said it best "It's all in the hands of the individual caseworker". She has the Band herself and is a real advocate. She has talked with understanding, caring case workers who "get it" and others who obviously think (as you have so cleverly stated) "it ain't my body". Let's hope for door number one! As a non-religious person myself, I'm not a pro at praying (may seem a bit hypocritical and trite to start now) but my thoughts and every "good vibe" I can muster are being sent to all of us in this battle.

Love your posts JB!

All my best "stuff"

Jill in NY

In for the long haul

[HelenC 0]

I have BC/BS of IL - Plan 121. They covered the surgery at 100%, after deductible, and fills are likewise 100%.

I did have to do 6 months of a physician supervised diet, but I had no co-morbidities, so that's probably why. I also had to provide 5 years of medical history showing I had a weight issue.

[Madine 0]

Mandy, I did not want to cause false hopes! But I was told I had no coverage, and after I persisted, FED EMP> BSBC said that after Jan.1 2007, I could have the procedure covered due to changes in the 2007 book, I was very excitted! If this did not apply to all I am very sorry! But I hope NO ONE gives up!

Ron

Ron, I have FED BCBS of Texas and they approved lap band if you meet the guidelines. However, they do not pre approve the surgery. You have to have the surgery and then make a claim with the requirements: medical necessity and 6 months of supervised dieting within the last 24 months. I have 4 letters from doctors with medical necessity but I do not have the 6 months of supervised dieting. BCBS said after the surgery they would review the claim and then approved or disapproved the claim. Now I don't know what to do. Has anyone had this situation? Please let me know. Thanks, Madine

[mamatouch 0]

I was banded on 2-14-07 and I have FBCBS and they have just paid the Dr's, I am still waiting for them to pay the hospital. They will not pre certify and yes I had to have 6 months of diet. Also had a letter from my PCP stating medical necessity. I had 3 of the 5 co-morbities. It was iffy at the least if they would pay, but I decided it was worth the chance. So I went forward and took the chance. I have lost 30 lb since I started the liquid diet on Feb 1, and no longer have acid reflux (woo-hoo) 4 pills I don't have to take now.

[airwayman 2]

I was banded on 2-14-07 and I have FBCBS and they have just paid the Dr's, I am still waiting for them to pay the hospital. They will not pre certify. It was iffy at the least if they would pay, but I decided it was worth the chance.

I have not been banded yet, nor has the Dr's. office received approval from BCBS (it is to be faxed today) so I haven't "been there, done that." But I don't understand how this happens. What can be "iffy?" If they paid the doctor, then you must have met all their requirements. What possible reason could they give for not paying the hospital? Sounds like to me you're home free. Good luck! JB

[piercedqt78 658]

I was banded on 2-14-07 and I have FBCBS and they have just paid the Dr's, I am still waiting for them to pay the hospital. They will not pre certify and yes I had to have 6 months of diet. Also had a letter from my PCP stating medical necessity. I had 3 of the 5 co-morbities. It was iffy at the least if they would pay, but I decided it was worth the chance. So I went forward and took the chance. I have lost 30 lb since I started the liquid diet on Feb 1, and no longer have acid reflux (woo-hoo) 4 pills I don't have to take now.

Sometimes the hospital takes long to submit the bills. I know that we had a trip to the ER and the doctor submitted right away, the hospital waited 3 weeks to submit their bill. I agree, if they paid the doctor I am sure they will pay the hospital. ~Mandy

[airwayman 2]

Sometimes the hospital takes long to submit the bills. I know that we had a trip to the ER and the doctor submitted right away, the hospital waited 3 weeks to submit their bill. ~Mandy

Mandy, there's a perfectly good explanation for this, the hospital didn't have a Porsche payment and alimony due that week. :phanvan JB

[piercedqt78 658]

good point! ~Mandy

[maltomeel 0]

I'M APPROVED!!!!!

I got the call today at work. Kim, the office manager asked if I was sitting down...and told me she had approval in her hands! 2 days! The papers were submitted Monday!

I'm on cloud 9. She will call tomorrow to set up surgery date. I'm hoping for 4/11 or 4/18 (Doc does surgeries on Mondays and Wednesdays....Wed would mean just three days off....(keep your fingers crossed for me).

What a day. I went straight to the gym after worked and sweated like a pig! I'm feeling soooo STRONG. Just acll me Bandita!

Jill in NY

BMI 41

Dr. David Mayer, Huntington NY

[NimbleBean 2]

Came home last night to a message from my surgeon's office. NJ Plus/BCBS approved me! It took only two weeks, and part of that time was waiting for my doc's office to send over some additional info.

Will be calling on Monday to schedule my surgical date. Can't believe it's really going to happen and I won't have to go into debt to pay for it.

Seems like a good day today!

:clap2:

NimbleBean

August 2006 - 285

March 2007 - 241 (after 6 month medically supervised diet)

? - 140 goal weight