Anyone have Blue Shield CA? question....

[swizzle 120]

2goldengirl, I actually am a CA resident. I made this account a long time ago and was hesitant to put my actual info in, but yes, I'm CA.

reachbree, I haven't gotten an official answer from BSCA, in fact they told me when I've called that the only way they give out requirement information is direct to the provider upon pre-authorization, which has been frustrating. And I was pretty surprised the surgeon's office was able to look at the policy and determine that it would probably be okay and that we'd go ahead with the three month recommendation. I'm sure that they will need to confirm this, and likely will run into the same issues yours did. But I think they feel like they policy clearly has changed and were pretty confident that we'd be able to go in this direction.

Now, I will be pretty bummed if we do this process and 3 months pass and I am denied and need to start back at month 1 of 6, making it a 9 month process. But I am taking the moment to feel optimistic, because my surgeon was so optimistic and confident! I don't think they'd go down a route that wouldn't be approved if they though it was unlikely.

But then I have no idea. It's a sea of different answers!

Don't give up! Think of how long you've been having difficulty with your weight. Even if it is 6 months, that's a blip! You can do it!!

[Sharon1964 2,530]

2goldengirl, I actually am a CA resident. I made this account a long time ago and was hesitant to put my actual info in, but yes, I'm CA.

reachbree, I haven't gotten an official answer from BSCA, in fact they told me when I've called that the only way they give out requirement information is direct to the provider upon pre-authorization, which has been frustrating.

As a member, you have the right to have access to the medical policies at Blue Shield. I would call back and ask for a supervisor. While you're at it, ask them to mail you a full benefits booklet and a copy of the bariatric surgery requirements.

[2goldengirl 2,076]

Actually, in CA, it's the law that criteria on which medical decisions are based must be available on request to providers, health plan members, AND the general public. Most CA H M O plans have their medical policies online available without a password. It's the easiest and most cost-effective way for them to comply with the law. Anybody at an 800# who doesn't know that is pitifully misinformed.

Try it. Google "Blue Shield of CA Medical Policy bariatric surgery"

And for heaven's sake, STOP talking to people who answer 800 numbers. They are not allowed to think. Ask, politely, to speak with a supervisor. Then when you get one, ask why the answers you are getting on the phone from their member services folks are not consistent with their policy.

And while I'm foaming at the mouth over this, the three-month timeframe is in no way a requirement, that's why the policy says "suggested". I once wrote health plan policies and I can tell you that if it was a requirement, it would jolly well say "required". Many people start and stop the process once or twice before they really are ready. Some, like me, don't need extra time for education in the changes my surgery will mean, thankyouverymuch. Blue Shield wrote this to give control to the surgeons. Unfortunately, they did rather too handy a job of it and everyone is flummoxed over it.

[reachbree 140]

Question.......Could the reason Im getting a different response from everyone is be my employer? Im hearing that policies are also based on your employer. For instance, even though 2 people have the same insurance (BS/CA, Ach Em Oh) lol they may have different policies and/or requirements, based on their employer or the plan that employer has.

So that is what this is beginning to look like. BS/CA may not have this requirement anymore, but my employer may have required it specifically in the plan they offer their employees.

[inhiskingdom 39]

I was told 6 months at my first visit yesterday but I had already looked up the policy which recommends 3 months from initial visit to surgery date. The dr office said they would look into it to see if it was true. I am hoping it's 3!

Edited January 22, 2016 by inhiskingdom

[2goldengirl 2,076]

I was told 6 months at my first visit yesterday but I had already looked up the policy which recommends 3 months from initial visit to surgery date. The dr office said they would look into it to see if it was true. I am hoping it's 3!

The three month period is suggested, not required. Big difference. the three month period is to allow for preparation and education - things like preop testing, sessions with an RD, that kind of thing. Do you have H M O or P P O?

Just be aware, many surgical offices CALL Blue Shield to verify that you have the bariatric benefit and to verify requirements. Unfortunately, many of their Provider Services reps don't both to look up the policy and will say you need to do six months because that's what they're used to. Demand (politely) that the office refer to the policy online directly for policy requirements.

[reachbree 140]

Thats awful that you call and getting the wrong information. Im sure it happens everywhere all the time however, when it comes to policy information reps should always be up to date....considering this policy changed 6 months ago...they should know by now.

I finally spoke to a rep who IS up to date. She ensured me that there is no longer a specified # of months within their bariatric surgery policy, which means its totally up to your provider (surgeon) if they decide they want you to be on a MSWLP 1-12 mo's which in most cases they do to help shrink the liver. I asked her how I can best transfer this CORRECT information to my provider and she gave me her extension however calling would be difficult, so my best bet would be to just call them and let them know I spoke with the rep and was informed of this change and the updated policy.....which i did before!

Edited January 22, 2016 by reachbree

[2goldengirl 2,076]

Question.......Could the reason Im getting a different response from everyone is be my employer? Im hearing that policies are also based on your employer. For instance, even though 2 people have the same insurance (BS/CA, Ach Em Oh) lol they may have different policies and/or requirements, based on their employer or the plan that employer has.

So that is what this is beginning to look like. BS/CA may not have this requirement anymore, but my employer may have required it specifically in the plan they offer their employees.

No, that isn't it. Employers may exclude the benefit, but they aren't allowed to dictate medical policy. And in five-plus years, I've yet to handle a Blue Shield of CA case that excluded the benefit. We did have one health plan (self-funded by a county for county employees) and they excluded bariatric surgery as a "cosmetic procedure". Oh, and this was a county with one of the highest obesity rates in the state. go figure.

Ask to speak to the office manager for your surgeon's office. Ask her or him to find the policy on Blue Shield's website, no password is required to view medical policies. Ask that they do this while you are on the phone (or standing there!). Understand that patients do sometimes lie to get what they want - this is why most MD offices are reluctant to accept the notion of change if it hasn't come down to them from proper channels.

Edited January 22, 2016 by 2goldengirl

[Yadie2006 75]

no !!! they dont require it anymore! mine was approved in 4 days!

[swizzle 120]

reachbree YAY!!! I'm so glad you finally got through the frustrating channels and now have what you need to move forward! Glad to hear that with persistence they're finally able to give out accurate information!

(although it shouldn't have required NEARLY as much persistence, as it should have just been correctly given to you by the first rep you called.)

[inhiskingdom 39]

I was told 6 months at my first visit yesterday but I had already looked up the policy which recommends 3 months from initial visit to surgery date. The dr office said they would look into it to see if it was true. I am hoping it's 3!

The three month period is suggested, not required. Big difference. the three month period is to allow for preparation and education - things like preop testing, sessions with an RD, that kind of thing. Do you have H M O or P P O?

Just be aware, many surgical offices CALL Blue Shield to verify that you have the bariatric benefit and to verify requirements. Unfortunately, many of their Provider Services reps don't both to look up the policy and will say you need to do six months because that's what they're used to. Demand (politely) that the office refer to the policy online directly for policy requirements.

Thank you for sharing your knowledge! I have a PPO

[reachbree 140]

no !!! they dont require it anymore! mine was approved in 4 days!

That's great Congrats!!!!

Question-What types of backup documentation did your Dr submit with the authorization? I am working on gathering some things that i think may help..not much but for instance I printed out my 24 hr Fitness gym visits in 2011 (only year i had constant visits but in 2012 I had a 20lbs weight loss following all of those gym visits!... So i printed my Dr.s weight charts from 2011-current and put notes wherever my weight increased, or decreased.

Do you think this is necessary? I've never had a supervised Weightloss plan (not even weight watchers) until now (supervised pre-op diet). I know this will probably hurt me because they want to see proof that Ive gone through supervised diets before right?

Also, my BMI is just a bit over 40 with no comorbidities (gee did i spell that right??). It wasnt until 5 months ago that I reached that BMI..before that I hovered around 38 and 39.

Edited January 22, 2016 by reachbree

[2goldengirl 2,076]

It shouldn't matter what your BMI was, only what it is. The policy doesn't say you must have had a BMI > 40 for any timeframe.

As far as the documentation, remember this: your surgeon submits the request. They do this all the time. They want to get paid, so they want you to be approved. They will ask you for anything you need.

and yes, you did spell "comorbidities" correctly!

[reachbree 140]

It shouldn't matter what your BMI was, only what it is. The policy doesn't say you must have had a BMI > 40 for any timeframe.

As far as the documentation, remember this: your surgeon submits the request. They do this all the time. They want to get paid, so they want you to be approved. They will ask you for anything you need.

and yes, you did spell "comorbidities" correctly!

LOL!! Thanks 2gg

So true, the policy wording is so important!