Rocket City Guy

Flowergurl, I really think FEP BCBS benefits are the same nationwide, taking into consideration whether one has the basic option or standard option. I think where some of the differences some of us have experienced are due to the way hosp and dr's bill for the operation. You mention your copays after deductible for the doctor and for the hospital, but do you know if you will be billed for the band itself? I myself was, and since the hospital billed it instead of the doctor, I was responsible for an additional copay of 30% of the allowable charge, as the band system is considered durable medical equipment...if my surgery had been inpatient instead of outpatient, I wouldnt have been responsible for any additional costs for the band. Going from what your post said, it sounds like you have standard option bcbs, so if you are billed for the band system by the hospital instead of doctor, you will have to pay 10% of allowable for that. So I guess I'm just trying to say its not just that we need to read our plan brochures (which we do!)...there are many different factors that can affect how our benefits are applied

[quote name= From my experience with FEP BC, surgeries have a $100 co-pay, as well as a $100 copay for the facility. I'm concerned that there might be a difference in how the actual band is covered under in-patient and out-patient surgery. I plan to call BC to ask on Monday.[/quote] Pennyt, Please post what you find out. I have Fed BC/BS, basic option, and had my band placed back in Feb. I had a $100 copay for the surgeon, and a $40 copay for the hospital, but like you mention above there is a HUGE difference in how the band was covered for my outpatient surgery (70%) vs. how it would have been covered if my surgery had been inpatient (100%). It ended up being almost $1600 copay just for the band! If anyone reading this has fed bcbs basic option and had their surgery done outpatient, please post and let me know how your band was covered, if it was different than I described above. Thanks!

Just a quick caveat on this...in order to get a tax benefit from this surgery, or any surgery you must file an itemized return and you can only claim the medical expenses that exceed 7% of your adjusted gross income. That said, you can include mileage or airfare to the doc, hotel rooms, etc, so save all associated receipts!. For more info, please see http://www.irs.gov/pub/irs-pdf/p502.pdf

2. I only use an urgent care clinic if I get sick, I havent had a "family doc" in 10 years or more. I just hope he will accept the records from a clinic. Im not sure how this will if you have a letter from a primary care doctor. Michelle, I was in the same boat. I very rarely get sick and have always just went to an urgent care....this was not a problem, in fact, they didnt request past records. As far as getting a letter from a PCP stating that I was fit for surgery, I just found a doctor that was accepting new patients, went there and explained my situation and that I would like him to be my PCP from here on out. He didnt have a problem with that, just said that in order to write the letter he would have to do a physical exam and some blood work in order to do so. He even worked with me on how to bill it so that the needed test were covered by ins. If your interested, the guy I saw is Dr. Plotka at Phoenix Urgent Care.....

I never thought that I had a sleeping problem either, but the test showed I had mild sleep apnea and I was prescribed a CPAP....and I never used it past the first 30min on the first night. I did not have a clue that it had a data card in it! I almost had a heart attack the first time I heard someone talk about one of those and really got lucky that my sleep doctor did not require me to bring it in or anything at all. I really think my guy was kinda a quack to tell the truth lol. For example, I kept telling him Dr. Schmitt required him (the sleep dr.) to write a letter saying I had been evaluated for sleep apnea and was being compliant with prescribed treatment.....buy the sleep doc just kept sending the results of the sleep study, with no letter or comments. Thank goodness that his receptionist took pity on me the 4th time that happened and made sure it was handled!

What you were told is correct, everything is COVERED...but the way things are covered differ between inpatient and outpatient. I dont think Dr. Schmitts office can give you a breakdown, b/c they dont bill for the hospital. The way I was billed was one bill from Dr. Schmitt for the surgery (covered at 100% with only a small copay to deal with), one bill from the hospital (multiple line items on this bill, everything from different meds to the band itself, to the recovery room. Many of These items were only covered at 70% due to outpatient status), and finally the anthesia bill, which should be covered at 100% no matter if surgery is in or outpatient. I'm speaking from MY own experience. You should call BCBS and get them to explain to you how your benefits differ between in and outpatient surgery. The part that I guess threw me for a loop was I thought I would only be charged the $16K or so they quote at the seminar as the cash price, and that benefits would apply to that. If you have insurance, that is NOT the case, there are MANY seperate charges and thus all of the different rules by which insurance will apply. BUT at least we have insurance, right? I bet that is as clear as mud, right? Send me a pm if you have any specific question. I really wish I had went with Dr. Kim Schmitt. It sounds like she was much easier to see than the folks I went to, even factoring in a two hour drive one way to get to her :biggrin:

Sorry, I may not have been clear in my last post. The anthesia is covered 100% inpatient or outpatient. But they give you other drugs, such as anti-clotting medicine for example, that are only 70% covered for outpatient.

Ask all the questions you can think of...I will be glad to answer. It really didnt seem like there were alot of hoops that BCBS required. Dr. Schmitts office sent them a letter, or to be more correct, filled out a standard form that BCBS uses. The form explained my history and current status of obesity. About three weeks after that I got a letter from BCBS stating that as long as my condition did not change from what was stated on the form, the surgery would be considered medically nessacarry. This is different from pre-approval, but it didnt cause me any issues. Now, Dr. Schmitts office did require a few hoops: 1. letter of being "fit for undergoing surgery" from my PCP. Very easy to get, as I am healthy as a horse, cept for being fat lol 2. Evaluation for sleep apnea. This area proved to be a huge holdup for two reason: First of all, it seems to be really hard to get an appointment with these folks! And then, its hard to get an appointment for the sleep study. And then you have to wait forever to get the results, etc, etc. Second, I think I messed up by not going to see one of the sleep docs recommended by Dr. Schmidts office. I didnt wanna drive to Bham for this, so I chose a local doc. My doc didnt seem to understand what kind of documentation Dr. Schmidt needed. So that was a pain and took forever!!! I highly suggest getting this out of the way first thing. These were the only two medical hoops I had to jump through. A psych eval was not required. Also you have to attend a lapband support group meeting and a nutrition class, but those were no problem to schedule. I did my surgery outpatient and felt fine going home that day, even if there was a two hour drive back to Huntsville. BUT, I was I had done it inpatient. Even though the surgery was covered no problem, different levels of copays apply to inpatient than outpatient. For example, if you look in the benefits book you mention, look at the benefits for durable medical equipment, which is what the band and port system is considered. If you do inpatient, it is covered 100% with no copay, but the same equipment is subject to a 30% copay if its implanted during outpatient surgery. That alone came to $1,600. Also, some of the drugs they give you before/during surgery fall under the same rules and arent covered as anthesia. Sorry for going on and on, but I was really surprised by the different levels of copays. If you have other questions or need me to put out what pages/sections these issues are on, send me a pm with your email...I wont bore the others on here lol. Take care! RCG

Hi there. I used Dr. Schmitt and also have Fed BCBS. I have the basic option, and got hit with some unexpected co-pays....but cant complain too much, bc it was still much much less than some folks have to pay. Not sure what option you have, but if you can manage to get the surgery done as an inpatient, it is much cheaper.

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.

but I think I've seen something from BC/BS saying that as long as you have the documentation, Weight watchers or Jenny Craig or similar programs can substitute for a Dr. supervised diet. I will look around to see if I can find that piece of paper that says that...I think I got it in the packet from the seminar I attended at St. Vincents East (Drs Miles and Schmitt). Also, you could probably just call BCBS and ask. Hope this helps and that it works for you!

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

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

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.

I do feel very fortunate and blessed that I have insurance that covers this procedure in any amount, as many arent in the same boat. Even if I end up with the copay for the band itself, thats a small amount to pay for the benefits I will receive. However, this is a situation that I havent heard any others speak of, with my insurance or any other type. Therefore, I'm trying to gather as much info as possible in order to determine if there is anything I can do to avoid the extra cost.

Too late for that, it's already either applied or implanted, whichever way you want to look at it lol.

Hey everyone, I posted a question at the link below concerning fed bc/bs insurance copays. I wanted to mention it here as well so that folks who have already had their surgery and finished up the insurance process would see it, as they might not be as inclined as pre-op folks to look at the insurance forum. By basic question is has anyone ever heard of a facility billing the band itself as an implant? This has caused my copay to go from $40 to almost $2,000!!!! For more details, please see my post at the link below. Any input is appreciated. http://www.lapbandtalk.com/f8/fed-birth-control-bs-co-pays-54536/#post747682

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!

Huntsville, AL here. I was banded 22 Feb 2008. I'm down almost 20lbs from day of surgery, and feeling great...very little pain after first two days.

I REALLY like Extreme Smoothies by VHT. a 12oz can has 170 Cal, 35 grams protein, and 6 Carbs. I've only tried the chocolate flavor, but it is really really good, almost like chocolate milk lol. The only issue is that I cant get them locally. The only place I've found them in Alabama in at the Apothocary at the Hospital where I had surgery. Today I found I was able to order them online, so that a positive.

Hi Everyone. Like a couple of folks here I was banded on 22 Feb. I'm feeling really great so far, the only issues I've had were some pretty severe gas pains the first two days, but like someone mentioned above, the more I walked around the better I felt. Yesterday was my first day on full liquids. For dinner I tried a cream of brocoli soup, which I strained to get the chunks out of course. I was amazed at how full i was after just half of it. I just hope I am able to get good restriction once the swelling goes down and I start getting fills! Good luck to everyone!

Well, I'm finally banded!! Everything went great with no surprises, thanks to Dr. Schmitt and the great staff at St. Vincents East in B'ham, AL, AND thanks as well to everyone on here that shared their stories and information. I really believe that reading the forums here made me so much more prepared for everything that went on. No problems to report, other than I underestimated folks when they talked about pain from the trapped gas...once that is gone though, I will have no issues to complain about! Again, thanks everyone for sharing and helping others be prepared.

Thanks for posting your experience. I go in at 5:30am tomorrow and it is reassuring to read over how it went for other folks. Good luck!

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I just wanted to say hello and good luck to everyone. I'm being banded on 22 Feb by Dr. Schmitt in Birmingham, AL. I will be interested to read how everyone does that gets banded in early Feb. I hope all goes well for y'all!