Anyone have Blue Shield CA? question....

[reachbree 140]

BTW Blue Shield has been very tough for me lately. They will not give me the # to their Pre-Auth department, and wont even transfer me. I guess all insurance companies are very different in who patients have access to speak to.

[2goldengirl 2,076]

You wouldn't talk to the pre-auth department at Blue Shield - that department only handles things that Blue Shield directly authorizes (like clinical trials, certain transplants, that kind of thing.

Have you called your medical group? Your medical group ought to be able to intervene. Remember in the pst where I told you that if you got any pushback from your surgeon to contact Blue Shield and file a grievance? That's what you need to do. Call Member Services and say "I have a grievance". "Grievance" is a magic word, make sure you use it.

And when they ask you what the nature of your grievance is, you tell them that your surgeon's office is not following Blue Shield's medical policy for bariatric surgery. Tell them that you are aware that Blue Shield's policy changed effective 7/31/15, but that because Blue Shield has not effectively educated their medical groups, you are being held hostage to a policy no longer in force.

Good luck!

[reachbree 140]

Thanks so much 2goldengirl!

Here goes the update and not a pretty one.

The surgeons office called Blue Shield to verify the policy information. Btw my patient navigator was so upset with Blue Shield...she said she was on hold forEVER and that when she finally got someone, they didnt sound very knowledgable.....funny because I felt the same way when i called....They were told that the requirement is 6 months, no less.

The surgeons office said if I wanted to I could do the 3 months and they can submit all of my paperwork to Blue Shield however, they will probably decline it and request me to do more or I have to appeal it and they would take "an even longer time".

So how can I file a grievance if Blue Shield/CA is telling them the policy states 6 months pre-op....

[reachbree 140]

BTW- This process is already a PITA!

[2goldengirl 2,076]

The grounds for your grievance is that their people on the phone are giving outdated and inaccurate information to their providers - in this case, to your surgeon's office. I can't understand why MD offices insist on calling when the information they need is right there on the internet, except that they also want to verify that the policy doesn't exclude bariatric surgery. I've yet to have a Blue Shield policy exclusion in more than five years of working with their members.

Thanks so much 2goldengirl!

Here goes the update and not a pretty one.

The surgeons office called Blue Shield to verify the policy information. Btw my patient navigator was so upset with Blue Shield...she said she was on hold forEVER and that when she finally got someone, they didnt sound very knowledgable.....funny because I felt the same way when i called....They were told that the requirement is 6 months, no less.

The surgeons office said if I wanted to I could do the 3 months and they can submit all of my paperwork to Blue Shield however, they will probably decline it and request me to do more or I have to appeal it and they would take "an even longer time".

So how can I file a grievance if Blue Shield/CA is telling them the policy states 6 months pre-op....

So here you go:

1. Call Blue Shield Member Services (the number on your card).
2. Say "I want to file a grievance"
3. They will ask you to state in general terms the nature of your grievance. You tell them: "Blue Shield changed their medical policy concerning bariatric surgery on July 31, 2015. Both my surgeon (surgeon's name) and I were told over the phone information that was contradictory to the new policy.
4. My surgeon's office won't proceed with submitting their request for my surgery based on this misinformation."

If you have the dates you called yourself (I know you called more than once) and the names of the people you spoke to and the answers you got, you can fax this information to them. Also write down what your surgeon's office told you (and who told you that at the surgeon's office). Fax it to 916-841-0999.

Then call your medical group (sorry, I don't know which group you're with). Ask to speak to whomever handles requests for bariatric surgery. Ask that person whether they are aware of the change in policy. If they are, let them know that your surgeon's office isn't following the new policy, and that you have filed a grievance with Blue Shield over it.

Good luck. And yes, I do this for a living. And a lot of other things as well. If it's any consolation, I had my first visit with my PCP about this in September. It was December before I could see a surgeon for an initial consult, and it will be late Feb. to mid-March before my surgery date. That's just about six months.

Edited January 15, 2016 by 2goldengirl

[swizzle 120]

I've been following this conversation intently, because I worry I'm going to face the same hurdle. I have my appointment with my surgeon tomorrow. I've printed out the pre-auth form and policy update, and have links to each in case they need to go to them directly. But I worry that they will run into the same issue when they call if Blue Shield CA isn't giving out current information.

2goldengirl, did you have to go through the grievance process? Or was your medical group or surgeon able to figure out the revised policy? Or do you know anyone who did have luck where someone was able to verify through Blue Shield CA the policy change and say "yep, that policy was revised! No more 6 months!"? As far as I can see on these forums, everyone is having difficulty with this.

Thanks so much for all your knowledge on this!

(Also, I know I should, but I don't know what my medical group is versus my insurance provider versus the surgeon. :/ )

Edited January 15, 2016 by swizzle

[2goldengirl 2,076]

2goldengirl, did you have to go through the grievance process? Or was your medical group or surgeon able to figure out the revised policy? Or do you know anyone who did have luck where someone was able to verify through Blue Shield CA the policy change and say "yep, that policy was revised! No more 6 months!"? As far as I can see on these forums, everyone is having difficulty with this.

Thanks so much for all your knowledge on this!

(Also, I know I should, but I don't know what my medical group is versus my insurance provider versus the surgeon. :/ )

A bit of both, actually. I didn't find out about the change until Late September, otherwise I'd have told my PCP on our first appointment. Then I had to change surgeons because the first had an office staff that, ahem, doesn't work and play well with others. I WAS able to determine that my medical group knew of the change. But I filed a grievance anyhow, because Blue Shield did a crummy job of educating their own staff and their medical groups about the change.

How to find out who your medical group is? Easy. Look on the back of your insurance card. There is the name of your PCP AND your medical group. They're also referred to as IPAs. Here's how it works in a nutshell: Your employer purchases insurance coverage from an insurance carrier (in this case, Blue Shield of CA). They agree to a health plan for their employees and the premium, part of which is paid by the employer, part of which is paid by the employees. Blue Shield contracts with medical groups throughout the state, who process authorizations and pay the majority of claims and provide other services for members. Primary care and specialty physicans contract with those same medical groups to get paid for the services they provide at an agreed upon rate.

You go to your PCP. She/he submits a claim to, for instance, Healthcare Partners (an IPA). Healthcare Partners pays the claim. Your PCP wants you to see a cardiologist. She/he sends you to a cardiologist who is also a participating physician in the same medical group. The cardiologist wants you to have testing done. They submit a request for authorization for this to be done at a facility contracted with your health plan. Healthcare Partners processes the authorization and pays the claim afterward.

In CA, in most cases, the day to day of managing authorizations is the responsibility of your medical group/IPA. This is why Blue Shield doesn't actually authorize your surgery - your IPA does. Blue Shield writes the policies, the IPAs carry them out.

Edited January 15, 2016 by 2goldengirl

[reachbree 140]

Got iT!

Unfortunately, I have yet to get in the habit of taking down names when calling to get info but will work on it. Needless to say I dont have any names of the reps I spoke with. I called about 4 times. Funny because the first time I called I was told "We do not have a specific amount of time for the pre-op diet, that is up to your Medical Group. The second, third and fourth time I got "Oh yea,...you are required to do 6 months".

Do you think I should start my calls over again just so i could get names this time? I understand that this could be vital information for the grievance.

[2goldengirl 2,076]

Got iT!

Do you think I should start my calls over again just so i could get names this time? I understand that this could be vital information for the grievance.

No, I wouldn't bother. You've spent too much time already. They ought to have a call log for your account that shows each call anyhow.

Edited January 15, 2016 by 2goldengirl

[Sandra86says 92]

The grounds for your grievance is that their people on the phone are giving outdated and inaccurate information to their providers - in this case, to your surgeon's office. I can't understand why MD offices insist on calling when the information they need is right there on the internet, except that they also want to verify that the policy doesn't exclude bariatric surgery. I've yet to have a Blue Shield policy exclusion in more than five years of working with their members.

Thanks so much 2goldengirl!

Here goes the update and not a pretty one.

The surgeons office called Blue Shield to verify the policy information. Btw my patient navigator was so upset with Blue Shield...she said she was on hold forEVER and that when she finally got someone, they didnt sound very knowledgable.....funny because I felt the same way when i called....They were told that the requirement is 6 months, no less.

The surgeons office said if I wanted to I could do the 3 months and they can submit all of my paperwork to Blue Shield however, they will probably decline it and request me to do more or I have to appeal it and they would take "an even longer time".

So how can I file a grievance if Blue Shield/CA is telling them the policy states 6 months pre-op....

So here you go:

• Call Blue Shield Member Services (the number on your card).
• Say "I want to file a grievance"
• They will ask you to state in general terms the nature of your grievance. You tell them: "Blue Shield changed their medical policy concerning bariatric surgery on July 31, 2015. Both my surgeon (surgeon's name) and I were told over the phone information that was contradictory to the new policy.
• My surgeon's office won't proceed with submitting their request for my surgery based on this misinformation."

If you have the dates you called yourself (I know you called more than once) and the names of the people you spoke to and the answers you got, you can fax this information to them. Also write down what your surgeon's office told you (and who told you that at the surgeon's office). Fax it to 916-841-0999.

Then call your medical group (sorry, I don't know which group you're with). Ask to speak to whomever handles requests for bariatric surgery. Ask that person whether they are aware of the change in policy. If they are, let them know that your surgeon's office isn't following the new policy, and that you have filed a grievance with Blue Shield over it.

Good luck. And yes, I do this for a living. And a lot of other things as well. If it's any consolation, I had my first visit with my PCP about this in September. It was December before I could see a surgeon for an initial consult, and it will be late Feb. to mid-March before my surgery date. That's just about six months.

If you gain weight within those 6 months, will Blue Shield of California deny you? I've heard both yes and no.

[2goldengirl 2,076]

If you gain weight within those 6 months, will Blue Shield of California deny you? I've heard both yes and no.

NO. they can't. First, there is no six months. If you're speaking of my particular situation, it depends on my BMI when I saw the surgeon or when I first saw my PCP about it (they're less than a point different)

There is nothing in the selection criteria about weight lost or gained - simply weight to meet or not the BMI requirement.

[Sandra86says 92]

If you gain weight within those 6 months, will Blue Shield of California deny you? I've heard both yes and no.

NO. they can't. First, there is no six months. If you're speaking of my particular situation, it depends on my BMI when I saw the surgeon or when I first saw my PCP about it (they're less than a point different)

There is nothing in the selection criteria about weight lost or gained - simply weight to meet or not the BMI requirement.

Thanks for always being so informative! I submitted to insurance for the 2nd time a few days ago, so I'm hoping I get good news this time around!

[swizzle 120]

Hey, okay so I have an update. I met with my surgeon today and the administrators did default to the "6 month" answer at first, but then I showed them the link to the pre-authorization form and the policy revision (provided by 2goldengirl) and with that, they thought it was sufficient to get the ball rolling on the 3 month suggested timeline, as per the new policy outline. Which I thought was awesome, and good for them for being good advocates for their patients!! So it seems that I am going to go through the process as outlined in the new policy, they will include that in my paperwork, and then submit for approval in three months!

I just wanted to share, because I was ready for the worst, based on some of the stuff I've been reading.

This was a pleasant surprise, and I'm very happy to report that - as it seems today - I won't have to jump through a million hoops!

Talk to me in three months if I'm declined

[2goldengirl 2,076]

@@swizzle, the new policy is for Blue Shield of CA H M O - I don't know what the policy is for Illinios. I've been very specific about California and H M O product ONLY.

This is the link for BCBS Illinois: http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=ia2d1toe&corpEntCd=IL1

There isn't even a "suggestion" for three months.

Always, always, always, read the policy. Know what it says. Hold your providers accountable for following it.

[reachbree 140]

Congrats on having a great Surgeons team! seems that it just really depends on who you see, which i know.

Here's what I was told by my surgeons team.... "The rep I spoke with says they do require 6 months, if you are insistent on 3 months you can but be warned they will probably deny it and we'll have to do the appeal process which can take much longer......"

Even though I gave her a copy of the new policy and Auth form.....

Now it seems that I am the only one who is having this issue....with BS/CA and my surgeons office.

How are you guys (and others Ive read through the site) being told by BS/CA reps they no longer require the 6 months and had a policy update 7/31...and Im being told by BS/CA reps the total opposite? now i'm beginning to think that this just isn't for me.....

I mean, are we calling 2 different companies..far as I know there is only 1 BS/CA......

Sorry for the rant, just very frustrating and disheartening.

Edited January 15, 2016 by reachbree