anyone else have BCBS for Fed employees in Ohio?

[abbylamb 1]

Hey there. I'm just curious if anyone else out there has Blue Cross and Blue Shield for Federal Employees in Ohio? And if so, how hard are they to get approved for the surgery? I've done the seminar, called them, found out what they want (no one mentioned the 3 or 6 month doctor supervised diet). All they SAID they want is a letter of medical necessity from the surgeon and the CPT and diagnosis codes. It just seems a little too easy. I haven't met with the surgeon yet, but I'm anticipating that the insurance is going to be the hardest part. Suggestions? Thanks!

[DianaG 0]

Abby, BCBS FEP, has the same coverage in all states. It does not matter what state you live in, or what state you have the surgery in. I live in Arkansas, but had my surgery in Missouri. The insurance paid 85% of the surgical costs after my deductable was paid. You will find this information in the book of benefits that BCBS sends to each federal employee ( or retiree) who has their insurance.

The only trouble I ever have with the insurance, is trying to explain to the billing departments of clinics, dr's, and hospitals, that the BCBS insurance for federal employees is different from the regular BCBS and will pay for things that the regular BCBS of that state will not. Sometimes they really have a hard time understanding that. The "R" at the beginning of your insurance number, designates that it is indeed federal employees insurance and has to be sent to a different office to be paid than the regular BCBS.

Usually, insurance is the hangup with getting the surgery approved, but that is not the case with our insurance. By the time the doctor's office submitted mine until the time it was approved was 1 week. Not bad at all.

Also, there is no 3-6 month diet requirement before surgery!!

So, if your dr's office keeps insisting that BCBS of Ohio does not pay, you keep insisting that you do not have BCBS of Ohio,and that you have BCBS FEP and that they do pay. You might even take in your book from BCBS FEP and show it to them!!!

I have reached the point, where I just ask if there is someone in billing that is familiar with filing claims with the BCBS federal insurance, and ask to speak with them.

You might want to do a "search" on this site, because I know that there is more information here about this subject. I remember responding to another thread, but can't remember the name of it.

Good luck to you!!

[abbylamb 1]

wow this must be a universal problem! when I first heard back from my potential dr's office, the first thing they said was that I had to go on the 6 month diet!!! I had to insist BCBS FEP does NOT require that, and only after looking into it again did she agree! Now she's saying I require a separate letter from my primary doc. When I spoke with the insurance co myself, they said they only needed a letter from the surgeon stating medical necessity. This is so frustrating!:confused:

[DianaG 0]

Ya got that right!

Keep at it and they will finally understand. Let us know how it goes.:confused:

[BetterMeCourtney 0]

Wow.. interesting. We're covered by BCBS Fed. I was also told I needed the 3 months of supervised weight loss. I would much rather not do that if I don't have to.

[abbylamb 1]

isn't this frustrating?!? :thumbup: Although, after getting my doc's office to agree that they insurance doesn't require it, they are now telling me they do, since people with nutritional counselling do better. I'm so aggravated with this whole mess just lately! I sent them a nice letter detailing exactly why I think they should make an exception to the 3 month rule, since I've been working at the diet portion way before I went to them and have visited dieticians. It's not that I'm against seeing a dietician---I'm just against having that hold me up. I'll see her as many times as they want me to as long as I can still get my surgery by the end of the year. Well, good luck to you. I'll let you know how it goes. Hey-if my doc agrees to it, maybe you can send yours a copy of the same letter!

[tiffanye 0]

how much are you guys paying for fills? mine are $100.

[DianaG 0]

Hello all,

My fills were included in the total cost for up to a year. I have only been banded since July 27th, so I won't have to pay for one before June of 2010. Don't know how much they will charge then, if I still have to have them.

Abby, since BCBS FEP does not require the supervised diet, I would see if they would even pay for the visits to the diatician/doctor for something they don't even require!! I would bet they would balk at that!

I had to see the diatician twice before my surgery and they did pay for those visits. She is always available for phone calls and emails about my diet. I attend a support group and the diatician as well as the RN in charge of the program are always there also. That adds up to a lot of supervision/time for conversation with her without having to go through the 3 month deal when your ins. doesn't require it.

I have learned over the last 42 years of having Federal Employee insurance, that you have to really be insistant that the billing dept. of doctors, clinics, hospitals, really, really understand that it is NOT like the local programs.

Good luck to you all.

[DianaG 0]

Hi again,

My husband has offered to add some more info here that might be very useful in dealing with your provider. So I'll let him type now:

The Federal Employee Health Benefit Program is an annual contract between insurance companies and the Federal Government. The benefits and requirements are the same in all 50 States. The booklet provided by the company you have chosen spells everything out; but, some things need a little additional explanation. However, if a procedure is approved by a company it is the same everywhere.....no exceptions. The coverage provided to Federal Employees is not directly related to coverage offered to others by the same company. Now, not all companies provide the same coverage.

Diana and I have elected Blue Cross Blue Shield (BCBS). When she started considering lap band surgery, she contacted the individual at BCBS responsible for the Federal program in both ARkansas and the one in Missouri to make sure that we would not encounter any problems. Both, cited the same necessities as far as co-morbidity, etc. was concerned.

My advice is to go to the individual responsible for the lap band program at your location. Explain that you are in contact with others who have had the lap band procedure and are covered by BCBS. Tell the provider that these folks are telling you exactly what they had to pay for and what was required prior to approval and that none of this can vary State to State because of the Federal contract. If you are still encountering problems ask the provider (Clinic, hospital) to call the Federal rep for your State.

Diana was asked to do some initial research by our provider. When she contacted BCBS they said, "That the Clinic is having you do their work for them. Usually we are contacted directly by the provider." But, they gave Diana the info, she gave it to the provider. We did encounter one situation where the provider was unsure about payment. They called BCBS and were told, over the phone, we will pay....do it!

O.K. I'm back:tongue_smilie:

Just another quick thought..The billing for the lapband at my clinic is separate from the billing for the rest of the clinic. They have one lady who does the finance stuff (ins. selfpay.etc) for the lapband patients. She is the one who called the ins. co and was told that yes indeed they will pay for the procedure.

If we can be of any more help, let us know. Also, if you haven't already, search for this topic on this site.

[abbylamb 1]

DianaG-you rule! I don't know what else I can say!:thumbup: In response to the other post about the cost of fills, I think it depends how the office is billing them. Some offices bill it as an office visit, and the specialist office co-pay ($30) applies. Some bill it as an outpatient procedure, so then that co-pay ($100) applies.

[BetterMeCourtney 0]

an update on my end- I just spoke with a really nice rep from BCBS. I told her about the discrepancies between what the clinic was telling me vs what other FEP patients were experiencing. She stated that they do require 3 months of medically supervised weight consultations in the last 2 years. So, in my case, since I have not had anything like that in the last 2 years, I am being required to wait the three months and go to their appointments. However, if you had 3 months of supervised care in the last 2 years then that qualification should already be met.

oh, and we're on the basic plan.. not sure if that matters.

Edited October 23, 2009 by BetterMeCourtney

[DianaG 0]

Hi again,

Sorry if I misslead anyone about this issue of BCBS FEP!:closedeyes:

I have had so much trouble getting people to realize the difference between our insurance and the regular BCBS that I jumped in to tell ya'll about my lap band experience with the insurance and I didn't even think about the difference between the standard and basic.

Courtney, I have standard and when you mentioned basic, I pulled out my booklet from BCBS FEP and read it again. I can see now where the difference may be.... On page 52 at the bottom of the page it says:

"....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 co-morbidities who has failed conservative treatment; "

I had a BMI of over 40, so if yours is between 35(with co-morbidities) and 40, it looks like that is where the medically supervised statement comes in. I apologize again for not checking it further before I spoke:blushing:.

Courtney, have they scheduled your surgery yet?

There is one thing that you might want to check out though, and that is the difference in the co-payment amounts between Standard and Basic. I know that the amount of monthly premiums is more for standard ($356.59) than basic ($216.48), but it also pays higher co-pays than basic. So you might want to see if it would be cheaper to change to Standard for a year, have the surgery, and they you could change back to the basic next year. There is an "open season" each year starting in November and during that time you can change companies, or coverages without any penalties or pre-existing conditions being a factor. Of course you will have to see how much the monthly premium for standard and basic will be in 2010!:w00t:

Again, sorry for causing any confusion, but hope some of what I have told you will be of help!

[BetterMeCourtney 0]

Diana, thanks for the info. I am actually right at 40 bmi. I'm 40.3 to be exact, which makes this situation rather frustrating since if I dip below 40, I won't be covered- I do not have any other issues. I even dressed rather heavily at my first appointment, heavy jeans and two sweaters, LOL, to make it above that.. The nurse even told me that even though they have to do the formality of the appointments, I really don't need to diet or try to lose during this time.

I'm a little freaked out that I'm having to keep a food journal, yet if I lose ANYTHING I won't be covered. lol. :closedeyes: Although I must admit that for the first time in my life I'm not watching what I'm eating, and the fact that I have been told NOT to lose is a little bit liberating. LOL. I can't remember the last time I wasn't ransacked with guilt for eating something like a PB&J. Oh the carbs! :w00t:

I was told the copay for an outpatient surgery such as this is $100 for each qualified surgeon in the room. I am assuming I will just have one. That should be it. The only stipulation is the surgeon has to be within the basic network. No issue there.

Thanks again for responding. I'm glad to have found this resource to help guide me along the way.

[bridget1701 0]

Hi! I have BCBS for Federal employees in Nebraska. Approval for me was a breeze. No supervised diet, etc. Approval from the time they received the paperwork was only 48 hours.

[DianaG 0]

Hey, Bridget that is great! Your approval was even faster than mine!

Courtney, I asked the RN in charge of the lapband program, at my clinic, about losing weight while pre-surgery. Not that I thought I would lose tons of weight before surgery:rolleyes2: I was particularly interested in what would happen if I lost weight while on the liquid pre-surgery diet. She told me that the weight that mattered was the weight you started at and that was what they based the approval of the surgery on.

You might check with whoever is the charge of the program you are in to see if they do the same thing. That might help. Although a PB&J sounds pretty great to me:lol:!!

I assume you are going to a "preferred" (by BCBS FEP)surgeon and hospital? It sure does save a lot of money.

You are all going to be so glad that you got the surgery! I am 3 months out now and have lost 32 lbs. When I went in to see my surgeon Tuesday, he said that I didn't need a fill now, but in a little while he would start "tweaking" the band to get me to the "green zone"! Can't wait!!!!!

Keep me posted on what goes on with ya'll. I am really interested and will be the "cheerleader" for ya!:closedeyes: