BCBS CareFirst Horror Story !

[trander27 15]

I started this process on Aug of last year calling my insurance and emailing to see if Bariatric surgery was covered. We even re-checked after Jan 1st to make sure coverage had not changed. They said it was if certain condition ect.. I did their 6 month structured diet etc... My surgeon verified my coverage, I have it in writing from them. I just finished all my testing and requirements and I could visualize getting a date. Now when I went to find out why they denied my paying on my psych visit they say morbid obesity is an exclusion entirely ! Nothing is covered. They are really sorry that no one figured it out until now. They will pay for all the bills up to now for their error but that anything else will be denied. Of course I am beyond devastated. If anyone has any advice or has heard of something like this ? They are saying that's it !

[lucy0911 58]

appeal the denial. Does your surgeons office have a billing dept that is versed in denial appeals? Are you in a no take back state? if you have an approval in writing in a no take back state they have to honor the auth.

[samuelsmom 670]

That is ridiculous and sounds wrong (though I am no insurance expert). I see you are in Georgia. Try contacting the insurance commissioner. The web site for complaints is http://www.oci.ga.gov/consumerservice/complaint.aspx

I also wonder if the exclusion is for the Psych services, not the surgery itself?

I also agree with appealing.

[trander27 15]

I can't thank you enough. Those are good idea's. I asked for the person I talked to put all this in writing and I will contact the state commissioner and see. I thought the same thing the denial was for the psych eval and that would be no big thing but it was for everything. She said I have been reading your correspondence and I have to tell you NOTHING with morbid obesity is covered and we have made errors. I have 5 emails stating my benefits and clarifying them and numerous calls as well as my surgeons office verifying insurance. I just finished testing and my surgeon has not submitted the surgery for approval, that was to happen today. Because of this forum I know I have to be pro-active so I was watching my insurance claims as they came in and caught the eval denial. I am not sure I can appeal the denial since it was never covered and a mistake ? I am waiting to hear back from the surgeon office, they are less than all together and don't inspire a ton of confidence. It is a bariatric center for excellence but from their office staff I don't get that feeling and the person who normally deals with insurance is out on maternity leave. Reeling from the shock and really appreciate the posts. Regrouping and will challenge it anyway I can and if not mentally packing for a trip to Mexico. I will never give up this fight with obesity !

[lucy0911 58]

Georgia is a no take back state. Once they give approval it should stand. I would call them out on it before the commission but if they give you grief absolutely file with insurance commission.

[trander27 15]

As I thought my surgeon's office said there is not much to be done, they are not much of a help.

As I have said the surgery was never officially approved, it was being submitted today. I just had verification of my benefits stating it was covered based on requirements I have spent the last 7 months following to the letter. I think this forum is so helpful so I am posting more than I normally would in case this can help someone else avoid this issue or better prepare. I really admire that you all take the time to do that. I have 7 different emails from CareFirst documenting what is covered in my policy. I called as well on 4 other occasions as well as documentation from my surgeon. What they are telling me is that from Aug 24th 2014 on 7 different occasions through 1/19/2015 the reps did not pull my policy but a general policy. They did not check my plan specifically and my plan it excludes anything related to morbid obesity. I am finding all this very hard to believe of course but it's getting realer.

Anyway the only not entirely helpful advice I got post drama from the insurance coordinator at the office is that I should have gone to my human resource office and gotten the info directly from them. My god I don't know about you all but my HR team is neither human nor resourceful and talking to them about something like this would not be my 1st choice. I read these forums, learn form you all and I made sure I had this all in writing after reading the crazy stuff that goes down. That said I wish I had gone down to my hr dungeon and dealt with the HR beasties, I was vain,embarrassed and worried they would think "oh great there goes are premium".

Anyway still taking all the advice given and asked the surgeons office to submit so it could be officially denied. I have sent Carefirst emails asking them to reconsider and copied the 18 pages of correspondence between myself and their so called agents. I have my complaint ready to send to the GA Insurance Commissioner on stand by.

[Sharon1964 2,530]

I think you're doing everything you should be doing. Did you have any comorbidities? On appeal, I might argue that the treatment was for those diseases, not merely as a tool to lose weight.

And I might use some phrases and sentences like, "I find it abhorrent that your customer service agents, for a period of XX months, and on at least XX separate occasions, assured me that this procedure was a covered benefit, when in fact it was not. You allowed me to have hope that I could finally live a normal life. You allowed me to have hope that I could fit into the world. You allowed me to have hope and then, you so callously destroyed that hope with nothing more than "oops, we made a mistake." Imagine having a fatal disease, being told for months that you could be cured, then hearing, "oops, we made a mistake". Your repeated mistakes have devastated me.

I know you can make an exception, and I implore you to make an exception for me, as you misled me for so long. Please make this right."

[trander27 15]

I continue to love this forum and the advice is so helpful. So I asked for everything in writing and responded back with 19 pages of documentation and the names and titles of 7 different associates at CareFirst that pulled my benefits and verified them to discuss my case. Just for good faith I got two extra names from my surgeon and a copy of their verification as well as from the phsyc eval.

I have had 4 phone calls from CareFirst today and 2 emails

The 1st just being another apology and stating that it was a mistake but that I was excluded. As suggested I used words like egregious error and system wide, epic failure for 7 plus months. I explained I now have two "almost" co-morbidities as I waited this 7 months which is true and documented in my file. That I made medical decisions that I would have made differently, I have other costs associated now not to mention the time and mental anguish. I now have adult onset asthma and pre-diabetes

All advice from awesome forum

I told them I would pursue this in anyway, I appreciate their kind response but an apology and addressing the issue with their associates was not going to be a satisfactory resolution and that I will be extremely diligent in pursuing this in and all ways available to me.

This last call was better, moving in a more hopeful direction. They have a meeting with today, a tribunal of sorts she called it to discuss my case and how this could have continued to happen, they will be reaching out to my plan admin as well. I told her to read the email with a CSRII when I was getting frustrated trying to get "exactly what needed to be submitted for WW structured diet". The CSR responding shared with me she was going through the process of bariatric surgery as well and understood my concern to get all the documentation straight. I said ask her to imagine after 7 months this happening to her. The Supervisor said I don't have to because I had lap band last year and I know I would be devastated.

You just never know do you

sorry long post but just feel like I need to give back in case anyone else goes through this, had I not had all your posts to read I would have been lost

[trander27 15]

They are going to make it right

After 7 months of misquoted benefits CareFirst is going to honor their mistake and grant my surgery.

I just want to thank all the people who take the time to post and write thier stories. You just don't know when what you write may change or save someone's life ( maybe a little dramatic but true in the case of morbid obesity). It was trending towards better news late last week. I found a really human CSR named Amber who was amazing and helped me, she was calling my surgeons office for codes etc... Anyway it can happen as you all have said. I was never covered and now I am getting surgery kind of crazy. The advice and the post I read where spot on and encouraging and that is so helpful.

As a by product it also gave me voice with my VP of HR. Since waiting for surgery I developed pre-diabetes. I was able to ask her why they would make bariatric surgery a plan exclusion when it would cost them between $20-$25k a year if I become a full blown diabetic each year ! Why they would cover 90% of all fertility procedures and abortions but deny something that for many will be life saving. She had no answers for me but it felt good to express my concerns and I am writing a letter to our CEO as well.

[Nyelaah 77]

Yay!! Congratssss. So happy for you

[Debbie Jean 406]

What fantastic news! You are a true warrior. This is just the beginning of your wonderful weight loss journey. I know with your attitude and energy you will be a great success ????

[geistmadl 1]

I am new to the board..waiting on approval. So happy you pursued this and it seems to be going in your favor.

[Jrs_lovely1 12]

I am so VERY HAPPY for you!!!!! This is wonderful news. You and I of course know we share Carefirst BCBS in common & all of the issues we have had, to finally come out with something positive feels GREAT!

I have an April date. Do you have one yet? Hopefully we can share that in common as well and continue to support each other.

Edited March 18, 2015 by Jrs_lovely1

[samuelsmom 670]

Congratulations! I am so happy for you! That is wonderful news and inspiration for anyone else who is struggling with insurance issues.

[losinit512 12]

I am so happy you were able to get your surgery covered. Another member of the forum sent me the link to your story. I am unfortunately in the same boat right now with Cigna and am beyond devastated. I am less than two weeks from my surgery date and everything has been paid for thus far, and Cigna provided documentation to me (both written and verbal) that the surgery was covered. They also authorized the benefit to my doctor's office before I got the ball rolling. I am fighting this so hard and just knowing that I'm not alone in going through this is so helpful. I'm sorry you had to fight it too, but your information is invaluable. Thank you!!