bcbs/il hmo..the med grps decide

[iwalktheline 1]

I couldn't figure out why i have to do this 6m diet because bcbs hmo il said there are no prereqs besides the referral from pcp. found out on obesityhelp.com in an old forum that the med grp actually decides if you will have wls and they have their own check list/prereqs. i guess they have an agreement w/bcbs. anyone else know about this?

[Shauna80 0]

Hey Iwalktheline,

That is very true. Even though BCBS doesn't require you to have a supervised 6 month diet before surgery, the group provider ( your employer) states they are requiring it, so BCBS is following your employers guidelines. BCBS is just the insurance provider, and your employer sets the parameters for what is going to be covered and their stipulations for the coverage. I hope this helps.

[iwalktheline 1]

that is interesting. ok so why are some people that have bcbs /il having such a hard time actually getting approved by bcbs. the nurse at my med group said that once people make it through the 6m diet and she submits the referral she hasn't seen a denial. but, she says most people end up not having the surgery because they miss a few months in between and such.

[Shauna80 0]

that is interesting. ok so why are some people that have bcbs /il having such a hard time actually getting approved by bcbs. the nurse at my med group said that once people make it through the 6m diet and she submits the referral she hasn't seen a denial. but, she says most people end up not having the surgery because they miss a few months in between and such.

I'm not too sure. This may be something or a stipulation that BCBS Illinois has. Things are so different state to state. I have BCBS/GA and I dont have to do a diet, and they cover 100% as long as its medically necessary and I meet the requirements. I do know that if you dont follow the guidelines, they may not cover you. So that may explain why people dont have the surgery because they missed a few months and didnt follow the guidelines. I hope you get approved, and I would recommend calling the insurance company, and talking to them. they may be able to explain things based on your coverage. Sorry I couldnt be more help.

[time2Bthin 0]

I am new to this forum... I had to do a 12 mo. diet with my insurance... BCBS HMO IL... Just finishing up my 12 mo. this month and I have not lost... Can the insurance deny me because of this?

[iwalktheline 1]

From what I have heard the Med Grp decides if you are approved for the referral letter and once BCBS has that you get the surgery. The nurse told me not to lose much weight during the diet or I would not get the referral. What med grp are you with? My med grp used to have a 12 month diet for HMO and 10% wt loss but recently changed that because so many people were complaining. Im sure some day these 6 month diets will be a thing of the past. I have a 25 year diet that I could tell them all about.:thumbup:

Please keep us posted on your progress.

[time2Bthin 0]

I will die if I did not have to do all this for the past year... what do you mean when you ask what med. group... I am BCBS IL HMO, Blue advantage... Dr. will be Sarker out of Loyola, Maywood, IL... I think I will be checking on all this today to see if this is true... I am just dieing to get the band already...

[iwalktheline 1]

It's great to have someone else w/bcbsil hmo. Hope we can keep in touch through all this. Ill just tell you what I know so far. My hubby works for cook county so whatever bcbs that is I don't know. 1st thing I did was call bcbs and ask if it was covered they said "it is covered 100% as long as there is a referral from your pcp" I said "but what about the 6 month diet and all that" they said "with bcbs hmo we let the doc/med grp make the decision. you do not have ANY requirements with bcbs except the referral letter" So I made an appt w/my pcp at Dupage Med Grp and had a long talk w/the RN who handles this stuff. She said that just w/in the last month they have decided that they won't require a 12 month diet or wt loss to get the referral, now it is 6m weigh in w/the nurse and a psych and nutrition consult. She said that since my BMI is borderline becareful about too much weight loss (doesn't that sound ridiculous..considering) or they won't give the letter. She said that most people start the process but never follow through because they miss appts and such.

ok, I do know a nurse that works w/Loyola and they are SOOO Strict. Crazy rules about getting a referral. Almost would think they don't want you to have it. So just keep going. Do what they say and demand your referral letter. Remember they work for you. Good Luck and keep me posted:thumbup:

[time2Bthin 0]

hello iwalktheline,

I did some work on this stuff today. I called my medical group and they said that it is different for each group. I am with Northwest Suburban IPA and they told me that they still require the 12 months diet... It is just my luck that I am the one with the 12 month wait.... But this month is my 12th month and I have finished all of my testing. I am waiting for the results on my sleep study (takes about 2 weeks I heard) Sooo, I am keeping my fingers crossed that everything comes together quickly. How are you doing... So do you have a 6 mo. wait? What month are you in and have you had any tests done yet... I am glad to talk to you too... it is amazing, I just joined last night and have already met some people exactly where I am.... Thanks for your responses....

[iwalktheline 1]

sounds like you're going to be banded soon. that sure is a long time, longer than waiting for a baby. I am only on month 2. It was such a big deal for me to actually go ahead and decide to have this surgery and then to have to wait is making me dought myself. I just started taking diet pills yesterday because I keep thinking maybe I can do this myself and I absolutely hate them. I just don't know why I do that to myself. I am on the border of bmi 35, but I have a ton of problems because of my wt gain so technically I qualify. I have lost and gained a total of 500 lbs in 25 years. Ive been a size 2 and a size 2x. Im just done with that. I don't need a sleep study, but phsych and nutrition. haven't done them yet. have you met with the surgeon yet? Tomorrow is my second weigh in and talk w/the doc. my pcp doesn't like wls so I don't even like to discuss it w/her.

I will keep you updated and want to hear any/all info you have. take care.

[bgaylz 0]

Hi

I have Horizon/BSCS Direct of New Jersey and they required a 6 month nutritionist visit November will be my last appt with the Kingley Institute I only lost 6lbs (on there scale anyway) I started at 224lb on 5/14/08 and as of 10/28/08 their scale read 218lbs,but when I went for my pre-opt appt I weight was 213lbs on 10/22 and I saw my obgyn on 10/23 weight in as 213.7lbs. My experience with Kingley has been one big sale pitch,but that just my experience when I reminded the nutritionist if possible to have my letter ready for the insurance company when I come in for my last appt she said I think you need to continue with me not once a month,but every 2 weeks so I ask her to give me a copy of my records of all the time she took my measurement etc.......ohhhhhhh she didn't keep a record or keep up with my measurement,but I made sure I said at each visit to say(boy I lost a lot of inches to see if she would take my measurements) anyway I said my PCP will have the last word.

Sorry if I went on & on,but I needed to vent