BC/BS Federal. Sleeve surgery submitted as outpatient?

[Nicie 9]

I have bc/bs federal. My paperwork was submitted as outpatient. When I found out about this, I called the dr's office and was told bc/bs will not approve sleeve surgery for inpatient???? The dr's office told me they submit the request as outpatient and then after the surgery is done, they request approval for two nights stay. I was told it will be just fine, don't worry. That just didn't sound right so I called bc/bs and was told they approve the procedure based on what the dr says is medically necessary. If the approval is stated as outpatient, you are responsible for 15%. If the dr requests two nights for observation after the surgery, you are still responsible for 15% of the entire cost. So, if the surgery costs $50,000, I would owe $7,500 instead of just $250!

Has anyone ever had this problem with the dr's office saying this is an outpatient only surgery for bc/bs and that is how they must submit the request? Does anyone know if it takes more paperwork to submit the request as inpatient? I am now really concerned that since the dr's office submitted the request as outpatient and it was approved, bc/bs will deny the inpatient request, if the dr's office resubmits.

I sent an email to the director of the bariatric center and am waiting for a reply.

[Jersrose43 837]

It really isn't the surgeon who has control here. At least not much.

The surgery is submitted as outpatient for many people. You are usually there for an overnight stay. If you are there for 24 hours or more than the stay can be converted to inpatient and at that point it's the hospital who takes over and requests the approval or sends a notification to the carrier.

You will pay 15% of the outpatient charges as follows :

1- bcbs has some really great rates. The hospital charge will be a charge but you pay 15% of what bcbs APPROVES. Which is significantly less

2- you will pay up to your total yearly out of pocket. At that point bcbs pays in full for the remainder of the year. All claims for medical services go towards a maximum out of pocket.

Call bcbs and find out what your max is and how much you've got left. That is your maximum payment.

Let me know if you have questions 20 year insurance vet

[Jersrose43 837]

And another thing. Claims are not paid based on what the auth originally stated. It is based on what is billed and if the hospital feels you're inpatient they'll update the auth.

[Nicie 9]

Thank you for your response. Question - If the doctor's office knows the surgery is for inpatient care, why not just get the approval for an inpatient stay from your insurance company in the first place?

BC/BS told me that if the surgery approval is for outpatient, that is how it will be paid. If there are complications, then the hospital can request inpatient status starting after the surgery. If no complications and you are there for just observation, you are responsible for 15%.

So why take the chance of paying so much more for the surgery than you have to when there would be no question if the original approval is for inpatient?

[Jersrose43 837]

A couple reasons:

your insurance won't approve an inpatient stay at the request of a doctor - it is really the hospital who has to intervene and they won't until they need to

Insurance won't approve it unless it's absolutely medically necessary. If the majority of sleeves are done in a 23 hour stay (they are) there is no need unless you have a medical condition that warrants it. Think severe issues like a heart condition, your age, certain co morbidities.

It's unfortunate but your 15% will cap off at the max out of pocket

[Jersrose43 837]

The folks who after surgery - as you posted - request the 2 night extension to inpatient. Is the hospital. Not the doctor.

The hospital will call/notify the carrier of the admission. Not the doctor.

All the doctor is able to request is his surgery approval and tell the carrier where you will be in hospital. Hospital then does everything else.

Yes this is normal

[Nicie 9]

Anyone out there who has had the sleeve surgery - do you remember how your pre-certification approval was submitted? I would love to get more opinions on this.

And thank you Jersrose43 for your input. 20 years insurance vet! Impressive! You certainly add an interesting perspective on this issue.

I hear what you are saying and appreciate the input. However, it is in conflict with what bc/bs told me. Please be patient with me.

I do have high blood pressure, diabetes, history of blood cloths and am 63 years old. Wouldn't you think that is enough to get initial certification for inpatient status? I do not want to put myself in a position where I am at the mercy of the hospital administrator. Is there anyway to get the hospital to request pre-certification for inpatient approval now?

[Jersrose43 837]

It's totally up to the hospital and you'd have to know who to call. But that would break from their normal process.

Is it a cost Issue because of the difference or more the concern that inpatient is more care?

They can always keep you for 3 days in the same day surgery unit. That's also a possibility. And still not inpatient.

[alamergrl 8]

i'm also an insurance vet and that is how it works......post op if you have complications that require a longer stay the hospital can request approval from the insurance company for inpatient status. Your care is determined by the physician but the payment is generally determined by the insurance company. I'm scheduled for a sleeve on August 12 and it was requested and approved outpatient. I'm going to hit my max out of pocket regardless so it's fine...... usually outpatient surgeries are paid in a lump sum and inpatient is paid at a daily rate (all depends on contracts) so outpatient is usually the most cost effective for all involved. You notice I use the word usually a lot because there are always variations to everything. Good luck and congratulations on your approval.

[Jersrose43 837]

Nicie have you gotten any assistance from your surgeon?

[Nicie 9]

Hi Jersrose43. Thank you for checking on me. The bariatric director contacted me yesterday and the insurance issue remains the same. I am hoping all goes well and it will be documented as inpatient after the surgery is done. Then, as you said, the doctor and hospital converse.

Today I got me surgery date - 8/28/14.

I appreciate your responses.

[NoDramaLlama 38]

I was just approved last week by BCBS Federal (Basic) as inpatient for my sleeve surgery on August 4th. My doctor submitted as inpatient and that's how it was approved. He always keeps patients 48 hours, 24 before swallow test, then another 24 on Clear liquids, so that's how they submit. I will have surgery 08/04 and without any complications will be released about noon on 08/06.

[Nicie 9]

Dear NoDramaLlama: Thank you for responding. I am so happy for you and hope you keep us posted on your surgery progress.

I called bcbs again today. Was told the approval was submitted as outpatient and will be paid based upon that submittal. May I ask how you were able to get this inpatient approval? Any idea what the dr did to establish the medical necessity for inpatient stay? My doctor also keeps you in the hospital for two nights and they said the surgery can only be approved as out patient surgery?? I am so confussed.

[Nicie 9]

Great News! I just couldn't let this outpatient approval go uncontested when others have had the surgery as inpatient and bcbs customer support told me it is covered based upon medical necessity and is not an out patient only surgery.

So, I had a conference call with the director of bariatrics and the people at bcbs who process the requests from the doctors office. Got this straightened out and the surgery will be approved as in patient. If the surgery was not approved as inpatient, I was ready to file an appeal with the federal employee benefit plan or with whoever handles the appeals. I was asking for a formal denial so that I would then have appeal rights. Did not have to go that route and inpatient it is!

I am so excited and can't wait until I get the new approval letter.

Edited July 25, 2014 by Nicie

[ramyers8679 5]

I have BCBS Federal standard option and I had no issue with them approving me for surgery. I had my sleeve surgery on July 21, 2014. While in the hospital, a representative stopped by my room the next day to check up on me and followed-up with me by telephone on Friday.