ccarter8219

PPO does stand for preferred provider organization, and I believe it depends on which state your BC/BS is a member of to which guideline is utilized. Each state has their own guideline. I work for the BC/BS of GA which is called Wellpoint, and it includes several of the states such as CA, NY, VA, OH, NC. I think there are more, but I cannot remember all of them. We are combining to an enterprise wide name of Anthem Blue Cross. Most states follow the 30-31 day rule for an answer to be completed on a request for precertification/prior approval/pre-determination. However it may be delayed if they ask the provider to submit additional information. Hope this helps.

Dry Swallowing is just swallowing air without food or drink. :confused: Crystal

I would find out from the coordinator why they stated I was "good to go" when I needed the 6mo diet. If the insurance company has approved the surgery without the 6mo diet, then by the majority of the state laws say they cannot take back what they have already approved.

Welcome to the site!!!:thumbup: There is a lot of information that as an successful bandster that you may be able to help with, and if you have questions / issues the others may be able to help you.

I can agree to disagree. However cheating on a diet is not the same as leagally lying to your insurance company. You have no contract with your doctor to eat what they tell you, it is your on conscious. And by the way, the newspaper companies also lie to gain a profit. They spread gossip and rumors. No one ever knows the whole story, they just give you what they think you need to know. I agree that it is sad that children cannot get experimental drugs depending on their policy, but the policies are for their own benefit. How do we know that the "experimental" drugs won't kill them sooner. If we pay for it then they will sue the insurance company because we paid for it. Insurance companies are damned if they do and damned if they don't.:crying: Crystal

I am sorry you feel that way. No matter what you say, it is still fraud. I am one of those "medidal personnel" you think receives bonuses for justifying denials, however we are people of integrity and follow the guidelines. The Physicians always do a second review if we cannot approve a request. The nurses never give denials unless it is a contract exclusion. BCBS does not have to allow for WLS. It use to be an exclusion to all policies. I too was approved with a low bmi, but I had the appropriate co-morbidities. If don't begrudge anyone who meets the criteria to have WLS, but if you don't meet then you don't meet.

They can request all of your medical records from all of your providers to verify the actual information. If they have any inkling of suspicion they will demand a full refund and file charges. Just because you got approved for a procedure does not guarantee payment. It is just a certification of medical necessity. You can justify it all you want but it is still illegal. If you don't answer to it now in this lifetime, you will have to answer to the higher authority. Thou shalt not steal, and lying to get an approval is stealing. crystal carter rn

This is insurance fraud!!!!!!!!!!!!! :crying: If you get caught you face not only fines but imprisonment. I work for an insurance company and it is looked at very closely. It may not bite you when you get it approved, but the company can audit your case and take away any money it paid and press charges for insurance fraud. Crystal Carter, RN

thank! I have heard of the Rotary Club, but I had never heard them called Rotarians.

I'm sorry, but what is a rotarian? Crystal

I have to agree that everyone need realistic expectations. Also, you want your skin to tone up as you are losing. If you loose too fast, your skin does not have time to adjust. Crystal :thumbup:

I know it is easy for us to be in a hurry for the weight loss to occur, but slow and steady wins the race. Remain positive and everthing will turn out perfectly. Have faith in yourself and your ability to work with your band. Remember your band is just a tool to assist you with your weight loss. I too am still fighting with the need to lose weight faster, but when I think of my overall outlook on how much better I feel, it makes it worth the while. Keep up the good work! Crystal Carter, RN

Be patient. You seem to be right on track. :smile2: You are still in your healing process. Average weight loss once healing has been completed is 1-2 pounds per week. You don't want to lose it too quick because it won't give you skin time to adjust. Also, it is hard on your kidneys, and you are more likely to loose your hair when you lose too much weight too quickly. Crystal Carter, RN .

Unless they updated it, I couldn't find onderland on that one. Crystal

Thanks! Everyone kept using it then I was not sure what exactly it meant.

What exactly is the definition of Onederland? :cursing: I am sure I am being silly. Is it pronounced like wonderland? thanks, Crystal

To find out whether or not it is a covered benefit or an exclusion, you can call the customer service number on the back of the card. Let them know you are interested in Lap-Band WLS, and they will tell you if it is included or excluded. PPO coverage seems to be better than HMO, but you can never tell. I am not sure about cigna, you would have to call their customer service number to see if it is or is not eligible (just like blue cross). You would need to know what group he is looking to join when he takes his new job. I hope all works out. Let me know if you have any other questions. Crystal Carter, RN:biggrin:

Hello, I am a review nurse for an insurance company. I have a couple of questions for you. 1 - What type of coverage do you have (HMO, PPO, etc.) & 2 - Does your group have an exclusion for WLS? If your group has an exclusion then they are rarely approved on an appeal. If your group is a self funded group, you can sometimes appeal to the group administrator to have the exclusion lifted. Let me know if you have any questions. I hope I can help. Crystal Carter, RN:rolleyes2:

I live in Lanett, Alabama however I cam up to Chattanooga, TN to have my Lap band surgery by Dr. Robert Sass at Memorial Hospital on 6/9/08 and have lost 28 pounds. :tt2:

I agree with Gary B, call your insurance company. They will tell you if they even cover obesity surgery. Even though you have already have the surgery, the fills are considered part of that surgery, and they may be excluded. Is this an individual policy, or a group policy? That makes a difference. If if is a group policy, you should be able to get a certificate of credible coverage to waive your pre-existing timeframe. Good Luck!

I was banded on June 9th.

Hello, I am Crystal from Lanett, Alabama. I had my lap band on June 9th. I have 2 children: Joseph age 15 (will turn 16 on July 27th) & RuthaAnne age 9. I work for Blue Cross of Georgia in Columbus, GA. I am a Clinical Trainer for the Utilization Nurses, so I know all the pain everyone who has blue cross is going/went through. I am looking forward to going out to play with my daughter, and spending time with my son (when he lets me ha ha!).

Hello, my name is Crystal. I am 37 (almost 38) years old. I had my lap band on 06/09/08. I am curious as to whether or not anyone else has had an inflammatory respons to their band? I had one shortly after surgery, and thought I was going to die. It felt like an elephant sitting on my chest and radiation up to my neck. Luckly my surgeon is very accessible and saw me right away. I had to be placed back in the hospital of steroids, fluids, and potassium. It took a couple of days but it got much better. 225/199.5/140 :thumbs_down: