Blue Cross PPO Prudent Buyer in California

[KingJes 0]

Hello All,

I have Blue Cross PPO Prudent Buyer in California for my insurance. I’m trying to find out if anyone else in California has this insurance and what their experiences have been like with this insurance provider and the lap band.

My concern is that they will approve the Bypass but reject the lap band. I am 5’ 9” and shy of 271 which would have my BMI at 40 but I will drink 4 gallons of Water if I have to! I thinks its BS to be rejected because we keep working out to keep from getting even fatter. That’s sooo lame!

Anyway, I have completed my nutritionist appointment who said I was a good candidate for the procedure. I have also seen the psychologist who also approved me to have the procedure. I have attended 2 different seminars now and I have a consult today with Dr. Patrick Coates in Modesto, CA.

I didn’t know this but Dr. Patrick Coates doesn’t do the Lap Band, he only does the Bypass. I have to see Dr. Antonio Coirin for the Lap Band but he is booked until November 2007 for just a consult! Maybe it’s time for him to bring in a partner?

Well, my train of thought on this is that I can see Dr. Patrick Coates and he can submit for insurance approval for the Bypass and the Lap band. If not, then he can submit for the bypass and then Dr. Antonio Coirin can basically see me “pre approved” which may help speed up a process that has already taken 2 months.

Anyway, if you have Blue Cross PPO Prudent Buyer in California as your insurance provider, please let me know if they approved you for the Lap band and what your BMI was/is and if you have any comorbities. Was it hard to get approved or pretty quick?

Thanks all

-jes

[peacebaby 0]

I have Blue Cross of California PPO, and they are paying a portion of the Lap-Band surgery. They didn't even mention bypass as an alernative for me. They do require you have the procedure done at a "center of excellence".

In order to get authorization, I had to have my primary and psych doctors write letters about my ability to understand and commit to the program. I also had blood testing, EKG, treadmill EKG. I also had to meet with a nutritionist and a life coach.

To tell you the truth, I was really surprised how quickly it all came together. Now I'm worrying (of course) whether akk the good news was bad info. But we'll take it a day at a time.

[antsmith101 0]

I have Blue Cross PPO of CA.

When I called they told me the coverage is 80%, is this what they told you? When do you pay for this and can it be done monthly payment?

They told me I had to go thorugh couple test also... are those the only test they asking for?

I have meet with nutritionist, did sleep apnea test (test positive... now sleeping with mask), diabetes, high blood pressure, and high clesterol, bmi 46.3, and possible gout

How long did it take you to get finish testing and get permission for surgery?

Thanks for any info

[mgordon1 0]

Hi - sorry for the long post in advance - but I think you find it helpful.

I have BCBS Prudent Buyer - State employee and I was going to use doctors Coates office to do the procedure. I then found out that the Dr Coiran(SP) only does the procedure and with BCBS they only want the procedure done at a center of excellence with is Good Samaritan Hospital in San Jose to do the lapband. Unless they have changed, Doctors Hospital in Modesto is not a center of excellence and I don't believe either Dr Coates or Corian practices at Good Samaritan. Needless to say, I switched doctors. My new doctor (Dr. Cirangle - Laparoscopic Associates - Weight-Loss Surgery San Francisco, Bariatric Surgery) has an office in San Francisco but does come to the Central Valley and Sacramento on a monthly basis.

I have been approved already for the surgery and am schedule to have it done on 11/26 at Good Samaritan. The doctors office was very quick, as I was going to have the RNY done (changed my mind). The only requirment for me was a psych eval (used the same one for the RNY), nutritionist consult, and prior records. Once that was submitted, it only took about two days.

As far as the cost, I am paying the 20% deductible to the hospital and they want it prior to admission. I thought it was a payment plan also, I was kindly told no and how much with me when I am going to be admitted. Check your policy also, because my employers policy requires an overnite stay.

If you any more questions, email or post.

[antsmith101 0]

Well I just canceled my holiday trip and stuff, after reading they want money piror to admission to surgery.

So average cost of surgery is like 15-18k and 20% is like 3-4k that is needed piror surgery. Glad i got some money saved away.

Thanks for the info. very helpful.

[peacebaby 0]

I didn't actually speak to my Blue Cross rep, though we left messages for each other. Once the tests were done, the approval came in 4 working days and I had the surgery the following week (last Tuesday!)

The surgeon's office provided me Blue Cross's expected coverage and the balance I would need to pay them prior to surgery ($4200 for surgeon and assistant). Good Samaritan never even brought up payments, I just checked in and gave them my insurance information and paperwork from the surgeon. That may not be usual?

[antsmith101 0]

Did Blue Cross cover all your cost for the test you had to do prior surgery?

Glad I canceled trip now cause i rather have money for surgery then wait couple extra month to save...

Glad to have so many helpful people on this forum =)

Thanks

[KingJes 0]

Well the center of excellence is true. I found that out today. I have been transferred to Fresno Dr. Higa will be doing the procedure.

I wasn’t told anything about only 80% covered by my insurance so that is good.

I hope to find out Monday what my date for the procedure is... woop!

-jes

[mgordon1 0]

OK - I am at work and I can't stay on here long. I read my previous post and note to myself, never type when I am tired.Another note, my insurance has a reimbursement provision for hotel and mileage due to the distance (50 miles) Check your policy and see if can get reimbursed for expenses.As far as Dr Coates and Dr Coiran go, they are extremely busy. They mainly due RNY, I can only imagine how busy they will be if they both start doing RNY and lapband.I have a question, for those of you who have already the procedure at Good Sam is there anything that you wished you had done or brought with you. BCBS requires an overnight stay on my policy and I wanted some ideas. Also, is there anything you wished you had done prior to surgery? Thanks in advance for all of your help

[antsmith101 0]

KingJes, you have Blue cross PPO of CA right? How many test did the doctor put you through after your visit and how long did it take to get your answer from insurance?

peacebaby, They told you that you have to pay 4200$? Did you pay piror like they asked or you end up paying later? Did Blue Cross of CA PPo also require you to have surgery at center of excellence?

Thanks all...

[rebellerina 1]

i am also curios of how long approval took i have blue ppo prudent they said i had to poay 3500 out of pocket expenses

[antsmith101 0]

My approval took less then a week to hear back from doctor office =)

I havent figure out how much I will have to pay yet... They said I have 400 deductible (paid), they cover 80/20 up 2000$ individual out of pocket and after that it covered 100%... something like that

[mgordon1 0]

My out of pocket is 3000 then everything else is covered at 100%. Also, check and make sure they you don't have a maintenance fee with your doctors office. My original doctor that was going to do the lapband was charging a $5,500 above my deductible. In total, my out of pocket expenses was 8,500.:faint: Once I talked to my Blue Cross PPO they informed me that my follow up for the lapband (fills, labwork etc) should be covered under my office visit .

I was referred to another doctor who actually has been in practice longer and teaches the procedure to the doctors in my area. I am very happy with him and my surgery is scheduled for Jan 16 08