Bcbs Of Illinois Hmo Question About Medical Policy...

[makemyownluck 785]

Not sure if anyone on here has bcbsil HMO that can answer this - but the medical policy has THIS tucked into it toward the end, and I'm wondering if anyone else also interprets this to mean that there is no longer a requirement for medically supervised diet?

2011 Update

Patient Selection Criteria for Coverage

A requirement that a candidate for bariatric surgery complete a formal, medically supervised weight loss programs of specified duration has been a fixture of HCSC bariatric surgery medical policy for some time. The rationale for this requirement was founded on review and interpretation of available evidence in the scientific medical literature, primarily national consensus guidelines. However, HCSC has decided to modify this requirement based on a current review of the bariatric surgery scientific literature related to required pre-surgery weight loss programs, and including consideration of input from bariatric surgeons and their professional societies. The HCSC policy will no longer require documentation that a morbidly obese member must have completed a pre-surgery weight loss program of specified duration as one of the criteria for benefit coverage of bariatric surgery. This change does not mean, however, that HCSC no longer believes that successful bariatric surgery requires multi-disciplinary support from the member's bariatric surgery program and a life-long commitment to life-style changes.

Anybody know about this? I called them today and the girl I talked to was clueless - she referred me to talk to my PCP and I already have an appointment with him for Monday. Any help would be appreciated

[indi1 66]

That is exactly what that means! I have BCBSIL as well and they changed the policy on the exact same month I finished my 6 month supervised visit How ironic, I thought. Looking back, I'm glad I had extra time to think about things and practice new eating habits, etc.

[makemyownluck 785]

I'm going to print this out and take it to my appointment on Monday and show it to my doctor. I don't want to delay the inevitable! Sneaky how BC put this in at the END of the policy, in the part most people never read!! But I'll still follow my doctor's advice, but I also want him to know I'm serious about surgery and want to pursue it aggressively.

Do you/did you have ***? What is the referral process like? How much "work" did you do with your PCP vs. your surgeon?

[makemyownluck 785]

That's meant to say do you/did you have H. M. O. ... the edits on this board are silly! lol

[chitowngirl 884]

Ok, this is blue cross's policy, however because you have an HMO there is another factor you have to take into consideration, your managed care dept or IPA. The managed care dept which is not bcbs is actually the people who would be approving the procedure. Hmo's are a very confusing concept, but if you do have your weight history and weight loss attempts, and do all the requirements it should be relatively smooth. Usually your request for surgery will either be reviewed by the managed care nurse or their medical director.

15 years healthcare experience

Feel free to pm if you have additional ?'s

[justbeth 18]

I'm in IL. as well and i have bluecross blueshield and i have to have 90 days of supervised weight management diet with a nutrionist before my paper work is submitted. I also have to make sure i make the 4 consecutive monthly visits or the process starts over.

[sramos89 260]

I have BCBS IL but it is a PPO, and although I am not approved yet I have too read this policy and in Feb 2012 and took our the 6 mo supervised diet. I think you can still have the diet as a requirement if your employer or doc req it.

[makemyownluck 785]

I talked to my PCP about it today, and I'm not sure if he's just unaware of the actual process or what - but I'm just starting to feel like I'm not getting anywhere... I call BCBS and they refer me to the PCP, my PCP seems vague when I talk to him about what I need to do before getting referred to surgery. I have a NUT visit scheduled already (soonest they could see me is 8/22) and now i'm just about to lose my mind figuring out where to go for a psych eval - the *** doesn't require a referral, so now I'm on my own finding someone who will take my insurance AND do a WLS psych eval... 4 calls so far, still no luck. UGH!!!

But - all this will be worth it when it's done, right? :\

[sramos89 260]

Have you tried just contacting the bariatric surgeon that you are going to have do the surgery and have his office guide you threw the process? I started with an informational seminar, met with the MD, and their insurance person and they gave me a check list of things I had to do. It is still a headache of appointments and follow up phone calls but I feel like there is someone who knows what is going on with me. I just called them again this morning and am being submitted to insurance today! I think you said you are an *** and I am on a PPO so I know that is probably the difference but since the bariatric office deals with both everyday they can help you! Don't give up! I won't and good luck!

July 21- Seminar and MD Consult

July 24- NUT Appt.

July 27- sleep Study #1

July 30- Psyc Eval.

Aug.3- sleep Study #2

Aug.7- Submit to Insurance

[makemyownluck 785]

good luck getting approved, sramos89! I hope you get an approval!

I don't know what doctor my MD would refer me to. I plan on calling my H.M.O. tomorrow to see if they can help - I want to get registered for the seminars/classes in the hospital that I would be in, but I really don't know which one I'd be in. I talked to my PCP Monday and he gave me the name of the MD he would refer me to (who I looked up and is a vascular surgeon), and said I would most likely get surgery done at Sherman Hospital in Elgin, IL. But they don't have a bariatric program! I don't want this done by a surgeon who doesn't specialize in bariatric surgery! I'm kinda hoping that he was wrong about that and I'll get referred to Alexian. The surgeon that he mentioned is also affiliated with Alexian, so maybe with the H.M.O I have to go to the vascular surgeon first then get referred to bariatric? IDK. I hope not. That seems like a waste of time AND my money (specialist copay is $60 on my plan!).

long story short, I'm lost. I'm just doing the other pre-op stuff at this point and we'll see what happens from there. :\

I have a psych eval on 8/23. What's it like?

[chitowngirl 884]

@ make my own luck.....is your psych eval with someone who soecializes in bariatric patients? Also usually when you you see the bariatric surgeon they have a specific psych they referee you to, as there are very specific issues that need to address before your insurance will approve the procedure, and not all psych know what to ask or how to evaluate bariatric patients. Let me know how it goes with your managed care dept.

[makemyownluck 785]

When I set the appointment, I specifically asked if they handled psych evals for WLS and they said they do... My PCP told me to get the psych eval so he could submit the request to refer me... but my plan recently changed so no referrals are done for psych care anymore. Supposedly it's to give the patient more choice, but I could really use some direction!

So I'm hoping since I specifically said I was coming for WLS psych eval, they will be able to do what I need... it's just a regular counseling center, tho. They seemed to know what I wanted. Maybe I'll call them tomorrow to make sure...

[DietDivaKJ2012 0]

Good day ladies! For those having troubles with insurance I have a suggestion. Suburban Surgical Specialists in Hoffman Estates, IL will do the insurance footwork for you! They will make the calls and lift some of that stress off of you. I was banded with them in 12/2009 but had to have it removed in 11/2011. I have kept off 40lbs but still not where I want or need to be. I am looking at the sleeve that I call permanent banding...lol. However, I am on Medicare now and it isn't covered.....yet! I hope this helps....best regards!!!

[isajck 229]

When I set the appointment, I specifically asked if they handled psych evals for WLS and they said they do... My PCP told me to get the psych eval so he could submit the request to refer me... but my plan recently changed so no referrals are done for psych care anymore. Supposedly it's to give the patient more choice, but I could really use some direction!

So I'm hoping since I specifically said I was coming for WLS psych eval, they will be able to do what I need... it's just a regular counseling center, tho. They seemed to know what I wanted. Maybe I'll call them tomorrow to make sure...

I have worked with H.M.O. before but never under these circumstances. I understand the gatekeeper rules which is why the PCP has to refer to a surgeon but once that happens, would you not be under their care with them submitting all additional referrals? I'm asking this because how are you able to jump to the psych eval when you do not even have a surgeon? As mentioned by someone else, surgeons usually have a whole team that they refer patients to who know exactly what info is needed to obtain for eventual insurance approval. I would probably wait on all of the pre-op stuff until contact is made with a surgeon and you've joined his/her program.

[makemyownluck 785]

I have worked with H.M.O. before but never under these circumstances. I understand the gatekeeper rules which is why the PCP has to refer to a surgeon but once that happens' date=' would you not be under their care with them submitting all additional referrals? I'm asking this because how are you able to jump to the psych eval when you do not even have a surgeon? As mentioned by someone else, surgeons usually have a whole team that they refer patients to who know exactly what info is needed to obtain for eventual insurance approval. I would probably wait on all of the pre-op stuff until contact is made with a surgeon and you've joined his/her program.[/quote']

My pcp wants me to do all this before he submits the referral for approval. I definitely think im gonna end up doing things twice but i can't get any other answers from anyone about what im supposed to do, so the only directions i can follow are that of my pcp. If i dont get where i need to be, i might switch to the ppo plan during open enrollment in January. But for now i have been told to do the psych eval and see a nut, so thats what im doin...