Fed BC/BS Co-pays

[Rocket City Guy 0]

Hi folks,

I've got a question on Fed BCBS copays. I have the basic option and used a BCBS Center of Excellence. I had no trouble getting approved, and originally thought I would only be responsible for a $100 copay to the surgeon and a $40 copay to the facility. However, it looks like the facility has billed the band itself as in implant, and the way my coverage reads, an implant during an outpatient surgery is only covered at 70%, which leaves me holding the bag for almost 2k. Has anyone had this experience? I've not read anything about this aspect on the forum, and the insurance coordinator from my surgeon says she has never heard of it, but cant do anything b/c she doesnt see what the hospital bills. I found out about this yesterday due to a reimbursement statement from my flexible spending account and havent seen any paperwork from bcbs or the hospital. I just wanted to get as much info as I can before I get the statements so that I know how to either go about fixing it or accepting my fate lol.

thanks!

[ronwifey 0]

Hi. I also have FED BCBS Basic and just got banded on 3/3/08. I stayed 1 night in the hospital so I had to pay the $100.00 and co-pay of $30.00 when I see my Dr.

I was also approved very quick. I received a letter from BCBS and I'll quote parts of the letter.

"The following procedure has been approved as medically necessary as defined by the member's Health Care Benefits booklet or Summary Plan Description" Goes on to state my Physician, facility treatment setting ; which states "Inpatient Acute".

"Service Procedure Code: 43770

The service Procedure Description " LAPAROSCOPY, SURGICAL GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC BAND ( GASTRIC BAND AND SUB CUTANEOUS PORT COMPONENTS)"

Does not say anything about "implant".

I called to make sure my provider and hospital was a "participating provider" and in-network provider and facility, and thankfully they are!

[Rocket City Guy 0]

Ronwifey,

From just reading the benefits brochure, I dont think this would be an issue if I would have stayed overnight (inpatient) as opposed to doing it outpatient, which really makes no sense to me. I'm really anxious to get the paperwork from the hospital and see if they made some type of mistake. I've read the forums here and never seen other fed bc/bs folks mention this.

[ronwifey 0]

Also, I remember when I called before surgery the rep. at BCBS told me it is better to be "INPATIENT". Maybe that is where the costs might come from. If you are outpatient then you may not be covered as much as inpatient. I hope you find the answers you need.

[globally yours 0]

Rocket City Guy

We have BCBS Federal, for the life of me can't remember if we're basic or standard option, but I do remember the rep telling me if the procedure was inpatient they would pay 100%, but as my drs do it outpatient I have to pay $2,400. Wish he WOULD let me stay a full 24 hours, but as my doctors are trying to get established as a center for excellence I'm sure they are shooting for outpatient.

Just a question. I have an appointment on April 10th with the surgeon, who will then submit all my paperwork to BCBS afterwards. How long was your wait to get approved if you don't mind my asking?

Thanks!

Melinda

[globally yours 0]

PS: BTW, I have to have my $2, 400 upfront before the surgery.

[Rocket City Guy 0]

Rocket City Guy

We have BCBS Federal, for the life of me can't remember if we're basic or standard option, but I do remember the rep telling me if the procedure was inpatient they would pay 100%, but as my drs do it outpatient I have to pay $2,400. Wish he WOULD let me stay a full 24 hours, but as my doctors are trying to get established as a center for excellence I'm sure they are shooting for outpatient.

Just a question. I have an appointment on April 10th with the surgeon, who will then submit all my paperwork to BCBS afterwards. How long was your wait to get approved if you don't mind my asking?

Thanks!

Melinda

Thanks for the infor Melinda.

I think it took about 12 days from the time my paperwork was submitted to BCBS before they issued a letter stating that the surgery was deemed "medically nessacary", which is as close as I could get them to saying it was approved. They say they dont do prior approvals, but if a covered surgery is "medically nessacary" they will pay for it. I will say that some people have stated they did get a prior approval letter....but I didnt worry with that, as I felt comfortable with the above explaination, now I'm wishing I had fought a little harder to get one!!

As far as the copay, I was told my the insurance coordinator at my surgeons office I would have to pay all copays upfront, and all they asked for was $250 for the surgeon (which doesnt make sense, bc the insurance booklet says it should be $100 per surgeon - did I have 2.5 surgeons lol?) and $40 for the hospital.

I hope you can work something out to get your procedure covered 100%

-RCG

[globally yours 0]

Thanks RCG for your input. Just trying to kinda make some plans. Would love to have my surgery the first part of May.

Hope things will work out for you. From what I've read of other insurance providers, BCBS Federal is a totally different animal.

Take care

[needtolose 0]

Hello, I am also on Fed BCBS (in MN) Basic option. I am schedualed for surgery on March 11th (this tuesday) and just checked with my insurance company and they said it would be about $100 for the surgery, $40 for the facility and depending on how they word the medications, up to 30% for meds.

[snowbird 2]

RCG,

I would really press BCBS on this, as they say the procedure is covered. I had standard option, not basic, but when I read over the coverage I don't see any difference. I think the claims processor you talked to is wrong; ask for a second opinion on it or talk to a supervisor.

My husband and I both had our surgeries paid for by BCBS, but his claim paid more than mine. The difference was just between the two claims processors and how they arbitrarily categorized the different parts of the band procedure. We didn't argue because I was afraid they would lower his payment to my level, rather than vice versa! But I think you have a legitimate reason to have them take a second look at this.

[ronwifey 0]

Hello, I am also on Fed BCBS (in MN) Basic option. I am schedualed for surgery on March 11th (this tuesday) and just checked with my insurance company and they said it would be about $100 for the surgery, $40 for the facility and depending on how they word the medications, up to 30% for meds.

I called again to make sure, lol. And that is exactly what they told me too. But I only paid that 40 fee (mine was 30 actually) when I saw my Dr. at my pre-op appointment. Paid the $100 when I pre-admitted at the hospital and that is it. SO far no bills in the mail so we'll see how my meds were worded.

RCG~ You should not have to pay that much! I would make sure the hospital get's it striaght with BCBS that it is not an implant and make sure they have the right CPT code also. Good luck.

[Rocket City Guy 0]

I called again to make sure, lol. And that is exactly what they told me too. But I only paid that 40 fee (mine was 30 actually) when I saw my Dr. at my pre-op appointment. Paid the $100 when I pre-admitted at the hospital and that is it. SO far no bills in the mail so we'll see how my meds were worded.

RCG~ You should not have to pay that much! I would make sure the hospital get's it striaght with BCBS that it is not an implant and make sure they have the right CPT code also. Good luck.

Thanks for the input folks, that just confirms my thoughts that the key to this is in how everything is coded.

[morganfrmn 0]

I have this same insurance and I have sleep apnea and they pay 70% for equipment. I think your stuck with the big payment because you did not spend the night. sorry dude.

How does this bc/bs basic pay for lapband fills....????

[Rocket City Guy 0]

morganfrmn,

I think you are right, shoulda spent the night lol...which makes no sense if you think about it. oh well, its still much much less than other people have had to pay.

as far as fills, I have no idea yet, but will let you know on April 2nd when I get my first one.