Blue Cross Federal Employee Plan: READ THIS

[Linda Hamsing Rosen 1]

I'm sharing my experiences for those who have Blue Cross Blue Shield FEP so you don't encounter the same horrific experience I am now going through. I had my surgery "pre-approved" which was actually simply a letter staing that it was an approved procedure assuming I met medical necessity (this is all the insurance would provide). Well, after the surgery, the insurance determined that they didn't think I met medical necessity. To make a long story short, I have hired Obesitylaw.com to help with my appeal and they say I have a really good chance. In my discussions with Kelley Lindstrom she explained that the doctor's office screwed up by not designating the procedures as inpatient. If they have designated the procedure as hospital inpatient (more than 24 hours in the hospital) as opposed to outpatient (24 hours or less in the hospital), the insurance would have HAD to have made a decision as to whether to prior authorize the hospital stay. I'm assuming they would have made that authorization and I wouldn't be having these troubles now. But since I was only scheduled for 24 hours, the insurance told my doctor's office that I didn't need prior authorization. This opened the door for the insurance company to disapprove my surgery after the fact. Again, this only applies to Blue Cross FEP. I hope this helps someone.

[snowbird 2]

FEP Blue told me they don't ever pre approve this surgery; they gave me the requirements for it to be covered and I made sure I met them, and I didn't have any problems. Sometimes it matters just which claims adjuster worked on it, and a different adjuster may come up with a different decision altogether. Did they specify what part of the requirements you did not meet? BMI? Co-morbidities? Psychological approval?

Have you appealed this through FEPBlue? I have had them turn down coverage for smaller issues and it has always been because they or my doctor just screwed something up. A phone call and a talk to a supervisor has always straightened it out for me, but sometimes I had to be nearly rude (okay, make that REALLY rude) to get to talk to the right person who could actually do something about my problem. Good luck! Dealing with insurance is one time that being nice doesn't necessarily work.

[pennyt 14]

I got the same letter before my surgery saying "it was an approved procedure assuming I met medical necessity." I got my EOB last week, and BC FEP paid all but $100 of the surgeon's fee. I haven't received the EOB for the hospital portion yet.

My surgery was out-patient, although I had the opportunity to stay overnight if I wanted. DH wanted to go home, so we went home.

[Linda Hamsing Rosen 1]

The requirements are BMI of 40 or above with nothing wrong or BMI of 35-39 with co-morbidities. They say that what was submitted doesn't show two co-morbidities which is ridiculous with a cholesterol of more than 300 and a fatty liver. I have not appealed yet. That's why I got obesitylaw.com involved. I noticed your BMI was 37 so you must have had co-morbidities to get approved? What were they and what evidience did you submit? Also, I didn't know they paid for surgery in Mexico

[TUNKNOWN 0]

let me start off by saying you wasted your money by hiring Obesitylaw.com. A little insight: if your surgery is outpatient it is a Fact that you do not have to precert your stay. If your surgery becomes inpatient...then you have to call your insurance, usually your provider (doctor) does that for you if not then you have like 72 hrs to do it your self. if some how everyone for got to do it then you can simply call the precert line and try to get one to retro-active back to your hospital stay.... If you got a pre- d approved, and your clm got denied all your DOCTOR has to do is refile the clm with a copy of the PRE D letter. But it is very important that you do your ck list before your surgery to make sure you qualify.