Blue Cross Blue Shield Federal

[ladybugnessa 0]

I'm new. I have Federal Bc/BS standard.

our surgery is covered 85% I'm not being told at this point of any prerequisites.

I do know that an office visit copay used to be $15 and this year it's gone up to $20

I can't speak to how our insurance will handle fills since we are just at the seminar level of investigating this process.

[LISAMARIE1158 0]

l also have B/C Federal, basic plan...l pay $30.00 co pay for my fills, and now l got a statement from B/C saying l owe the Dr another $175.00 per fill..Appartently the Dr office charges $660.00 for fills and bills it under surgery..lmagine, l'm there in the office, no fluroscope, for about 2 minutes...and its $660.00 dollars....something is seriously wrong with this system..

[bklyn1984 0]

l also have B/C Federal, basic plan...l pay $30.00 co pay for my fills, and now l got a statement from B/C saying l owe the Dr another $175.00 per fill..Appartently the Dr office charges $660.00 for fills and bills it under surgery..lmagine, l'm there in the office, no fluroscope, for about 2 minutes...and its $660.00 dollars....something is seriously wrong with this system..

Thanks for this information. I have not needed a fill yet. I am going next week and will find out how they bill since fills are done in his office. I pay $20.00 co-pay now so if he bills like yours wow that much for a fill! Yikes!:tt2: I hope I can stay restricted like I am without ever needing a fill

[wannabthinagain 0]

any of you with BC/BS federal standard ever have problems with them paying for the surgery after saying it was approved?

right now they are telling me i'm approved, it will be $300 for hospital, and 15% up to $5,000 (which it shouldn't be anywhere near that) then it's 100% covered.

BUT...i know when they approved shots for my premature baby 2 years ago to have RSV shots that where CRAZY expensive, AFTER the 6 months/6 shots were given, BC/BS took the money BACK from the pharmacy the shots were from, and told US we owed them the money.....at the sum of $24,000!!! for SIX shots!

we fought the charges, did the appeal, they still denied paying it, then we went throught the next step before they FINALLY decided to cover it!

i have this little fear in my head of this happening...not enough to make me cancel my BAND date of 3/3/09 though! LOL

it will be worth every penny if we ended up paying for it, but i was wondering if any of you had to fight to have it paid after getting a pre-certification approval?

thanks!

[bklyn1984 0]

right now they are telling me i'm approved, it will be $300 for hospital, and 15% up to $5,000 (which it shouldn't be anywhere near that) then it's 100% covered.

I had a deduction of $300.00 which they have already applied to my surgeon's bill. I do not know about the hospital part yet because the hospital has not billed them. But I do know that I will pay $200.00 for a copayment. I had emergency surgery in December and only paid the copayment at that time too.

What is the 15% for? I am not aware of the 15% for the hospital also. There is nothing mentioned about this in my benefit plan brochure and I have standard also. I know my I am responsible for 15% of the plan allowance for my surgeon, the anesthesia, and the radiology. You only pay 15% of what the plan pays them.

For example here's my surgeon:

Billed Amount: $3,750.00

Covered Charge Amount: $3,750.00

Medicare / Other Ins.: $0.00

Deductible Amount: $300.00

Coinsurance Amount: $110.83

Co-payment Amount: $0.00

Amount Paid: $628.09

What You Owe This Provider: $410.83

Edited February 21, 2009 by bklyn1984

[Grider 92]

sure like to know wha this looks like in 2011 with basic.. like nobody really talks about it,

[Cocoabean 430]

sure like to know wha this looks like in 2011 with basic.. like nobody really talks about it,

You mean 2012? www.opm.gov/insure

http://www.opm.gov/i...ures/71-005.pdf is a link to their brochure.

Basic:

Preferred: $150 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $150 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about "agents.")

Participating/Non-participating: You pay all charges

Note: Prior

Gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 18 or over

Note: Benefits for the surgical treatment of morbid obesity are subject to the requirements listed on page 54.

Preferred: 15% of the Plan allowance

Participating: 35% of the Plan allowance

Non-participating: 35% of the Plan allowance, plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 17 for more information.

Preferred: $150 copayment per performing surgeon

Note: If you receive the services of a co-surgeon, you pay a second $150 copayment for those services. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about "agents.")

Participating/Non-participating: You pay all charges

Note: Prior approval is required for outpatient surgery for morbid obesity. For more information about prior approval, please refer to page 15.

• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. The member must meet all requirements.

- Diagnosis of morbid obesity (as defined on page 53) for a period of 2 years prior to surgery

- Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see page 35 for our coverage of nutritional counseling services.)

- Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise

- Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective

- Psychological clearance of the member’s ability to understand and adhere to the pre- and post-operative program, based on a psychological assessment performed by a licensed professional mental health practitioner (see page 86 for our payment levels for mental health services)

- Member has not smoked in the 6 months prior to surgery

- Member has not been treated for substance abuse for 1 year prior to surgery and there is no evidence of substance abuse during the 1-year period prior to surgery

[Grider 92]

I got the info from the ins co, just dont know if Ineed money day of pre-op (19th)or the day of surgery, and if it's the $75 for outpatient and $150 for surgeon, or what else? I called hospital, she said the ins coord would call me sooner to surgery. That is one more paycheck away. I just dumped $1800 on a transmission, so trying to see all options. If I am billed for the 30% stuff I'll be OK.

[jennilamb007 10]

I have FEP Blue and I was approved literally in 24 hours. I was stunned...so was my surgeon's office. My surgery copay was $150. It is my understanding with the office that the fill co-pays will be $35. Even if it was $100 each time, it is a whole lot less than paying for the entire surgery out of pocket.

Jen

[Grider 92]

_{Did you pay that at hospital, do you rem? I just want to make sure I have what I need the day of surgery. or for the pre-op}

_{Oh yea the fills, I didn't think they be much... I am very happy with FEPBLUE right now}

[MelindaH 3]

With the basic plan, do you have to pay 30% of the band?

With standard or basic, does anyone know what happens if band has to be removed for whatever reason, will they pay to have a second band placed?

Thanks in advance,

Melinda

[MelindaH 3]

With the basic plan, do you have to pay 30% of the band?

With standard or basic, does anyone know what happens if band has to be removed for whatever reason, will they pay to have a second band placed?

Thanks in advance,

Melinda

[Grider 92]

Thats some great information! we should have our own forum!. I am preparing with $75 outpatient fee and $150 for the surgeon. The rest hopefully is billed. I do know different states and doctors have different fees and requirements. I pushed to be done before 12/31 as my CO- insurance is about $1600 already- so Id owed about $3400 max. Why do you have to go to same Dr for fills? I saw one Dr. here filling for $40 and Mexican banders go to him and he is in a BIG gen hospital, so any reason to have to stay there? I was also told by FEPBLU that they pay for band removal if they have it take it out. Not sure if they will replace or you have to wait again.

[Grider 92]

Thats some great information! we should have our own forum!. I am preparing with $75 outpatient fee and $150 for the surgeon. The rest hopefully is billed. I do know different states and doctors have different fees and requirements. I pushed to be done before 12/31 as my CO- insurance is about $1600 already- so Id owed about $3400 max. Why do you have to go to same Dr for fills? I saw one Dr. here filling for $40 and Mexican banders go to him and he is in a BIG gen hospital, so any reason to have to stay there? I was also told by FEPBLU that they pay for band removal if they have it take it out. Not sure if they will replace or you have to wait again.

[Cocoabean 430]

Grider, sorry I misunderstood your question. I have bcbs *** so cannot answer specifically, but my hospital co-pay was due when I did my pre-admission stuff a few days before surgey. They would not proceed without payment. That was my experience, you might be able to work something out in advance.

Melinda, look at the brochure link I posted, it speaks of a second surgery. Insurance companies will pay for band removal if medically necessary. I am not sure about paying for a new band. Sorry I am of little help on that question.