OK folks .. I'm trying something and I'll let you how it goes.

I am a benefits/HR person for my company, and it was at the BCBS SC office this past summer that I was at their office for "train the trainer" meetings... it was there that I found out that our SPD ALLOWED for WLS, because I am HR, I am the main contact for my company with BCBS and we were given a special person to be our contact......... anyway... I just sent HER the following email: (btw thanks for posting the billing codes)

Hello Lisa!

Here at the Mother House location, we got our new ID cards in Tuesday’s mail. YEAH!

I have a question for you. In 2007 I’m going to be having a Lap Band put in,

CPT Billing Code: 43770 – Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).

I’m also enrolled in the CDHP (HRA plan), and utilizing the FSA.

I know that in our SPD we have a provision for it, my question for you is there any special paperwork for OUR PLAN that I will need to complete. I know a couple other employees have approached me already with the same kind of questions, and I want to help THEM as well as myself……….PLEASE HELP.

My surgeon is a Teir 1 provider and the hospital is a Tier 2.

Thanks for all your help!

CROSS YOUR FINGERS FOR ME!!!!!!!!!!!!!!!!! I want to be a bandster EARLY in 2007

Oh and this was my email back to the surgeons office this morning.

Hello Rachel, I just got this email today (Friday morning). I will give you a call later this morning.

Thanks.

I think how this will work is that technically, I don’t have to have a pre-cert, but to get speedy payment on my claims. I am going to have to prove medical necessity….. I think this may be a loophole in our plan and they didn’t realize would happen because our enrolment books clearly state for those with the CDHP, *NO pre-certs or copays on ANY service*

I’ve already got confirmation of this from 2 supervisors at BCBS. (I’m the HR person for my company), and I actually had to GO to Columbia SC last summer for a train the trainer meeting where I toured their headquarters/call center and met all these same people…. After they went back and pulled our policy for the CDHP both came back with the NO PRE-Certs allowance. (It is why I chose the CDHP over our PPO plan) I am committed to getting this pushed through, and I have all their names and numbers

I’ve attached their Morbid Obesity policy from their website.

www.myinsurancemanager.com/kc

Policy, Surgery, Morbid Obesity WLS

Thanks for getting back to me, and all your help

Tracy

Tracy,

I envy you for your knowledge! You are going to get this done and probably in record time too. I've been jumping thru hoops since October and I'm still waiting for letters from 2 docs before the Surgeon's office will even contact my insurance co (Midwest Security).

Keep us informed as you fight the good fight,

Bill

this is hot off my email...

Dear Tracy,

I do not work on Fridays; I just happened to stop by for a moment this morning and checked my email. If you would like to call me on Tuesday I would be happy to talk to about this. It sounds like you have done your research so I don’t know how much more help I can be until you come in and see Dr. Malley and I can get your Insurance information to call and talk to them myself. One thing that may be causing the confusion is that you keep saying you don’t need a pre-cert, what we send in is not a pre-cert, we call it a pre-determination and it is a completely different process. A predetermination is actually a review of coverage determination, based on the medical information that is submitted by the surgeon. If you want more information on this before your appointment, you can call your insurance company back. This time I would give them the specific code for the Lap Band 43770 and ask them the “predetermination” process for that and any and all criteria that there is. I could not find the bariatric policy from the link that you gave me, so I can’t see how it reads. If under your coverage it says that morbid obesity is covered if “medically necessary”, right there it is saying that it needs to go under a review for an approval. I truly think that the misunderstanding is with the word “pre-cert”. For all of our surgeries, we never obtain a pre-cert number, we either get an approval or denial based on the review of coverage. I would be happy to discuss this further with you, if you want to give me a call back on Tues. I hope that this helps and have a great weekend.

Sincerely,

Rachel H.

OK.... now I'm on the trail of emailing the supervisor in the Managed Tier department at BCBS SC, and copying in the insurance coordinator at the surgeons office... they should approve me just to get RID of me! LOL

Good Morning Cindy:

This is Tracy ID # xoxoxoxo and I talked to you a couple days ago about Pre-Certification for the Lap Band, Billing CODE # 43770 on our CDHP plan.

I really appreciated you getting back to me so quickly.

The insurance coordinator at my doctor’s office wanted me to ask you what exactly is thePREDETERMINATION process. She said I should do this before my appointment on Monday, and so here I am asking you.

I went and looked up the policy on the http://www.myinsurancemanger.com/kc, but didn’t really see anything too different that what is stated on our SPD.

I have a BMI of 43.6.. which means that I’m 5’5” and weigh in at a whopping 263.8……… I have lost the same 80 lbs 4 times in my adult life, but I’ve never been able to maintain it, that is why I want the Band… the band is a tool that will help me to once again achieve the loss but also aid in maintaining it.

I would appreciate it if you could look up our policy and then let me know what exactly the Predetermination Process is.

I have $$$$ in my HRA account, and my out of pocket max loaded on my FSA card.

Thanks for all your help.

Tracy

TracyinKS I've been watching your case but not posting. I'm now posting.

You're right there I can feel it. I can only add that I wrote a letter of impact myself. My BMI is (in a dream last night it was written in white, 61, on a red placemat. Anyone do dream interpretation????

I called BCBS and asked for my SPD, I want a copy so I can look for loop holes. When I asked Customer Service for a copy, she acted like she had no idea what I was asking for. She said they didn't have access to that. I took it to the next level. This person did the same thing. She told me to contact my employer. A friend of a friend told me that we have a legal right to our SPD's. True? What's up with that.

So quick question is there a claus for medical necessity?

I love your grit.

LapDancer:

YOU DO have a right to your Medical SPD, and you SHOULD be able to get it from your Human Resources department! (we give them out every year at open enrollment) and just so you know.... when I was at the BCBS SC headquarters for the dog and pony show... they bragged to us that the people dedicated to OUR account would have our SPD ONLINE, so that when one of our members called they could bring it right up...... I would question your BCBS about this when you call......

Oh and the supervisor for managed teir didn't give me her email, I just imput her name in the same format as the contact email I did have.. I had to play around with spellings but I finally hit one that didn't come back as an error..... (and I haven't heard back from her yet)

this is what our SPD says on the subject and this is from an email directly from our DIRECTOR of CORPORATE BENEFITS (i.e. the head hauncho at Corp)

Notice Wausau was our OLD insurance and BCBS SC is the new

He sent me an excel spread sheet that was titled bariatric surgery....

Now to me this is pretty vauge.... although it DOES look easier under BCBS.... especially because I'm in the >40 range

BCBSSC

BMI must >40kg/m-2

BMI must >35kg/m-2 with associated complications (diabetes, hypertension, obstructive sleep apnea)

The first treatment must be dietary and lifestyle changes. When this fails, surgery may be considered.

Wausau

BMI must >= 40kg/m-2Review conditions that are exasperated by the obesity.There must have been structured diet attempts that are physician monitered prior to surgery.Must be considered morbidly obese for at least three years

TGIF!!!!!!! just got this off my email from BCBS SC...

Tracy,

Hi. Sorry it has been awhile for me to reply. It has been a very busy.

I will try to summarize our predetermination process. Our nurse reviewer will receive the clinical information submitted from your provider, including your history and the surgical codes. Although you have offered most of this information personally, we need to accept it from the actual provider to complete a pre certification. All information is submitted to our medical reviewer. Then, the nurse will contact your provider with either an approval and authorization number for claims assistance or a denial along with the reason the procedure is denied. If additional information is needed, the nurse will let you know.

I really can not assist with benefits questions, but I hope this helps with some of your questions. Please feel free to have your physician submit the clinical information along with the code for surgery to us at 803.264.0181.

If I can be of any further assistance, please let me know.

Thanks,

Cindy

Clear as mud! (not really but clear at any rate) Sounds like they want it from horse's mouth. Fine.

Thanks for the quote. I just need to see that for myself in my own benefits package.

Do you know criteria for exclusions being reconsidered and determined necessary as in medically necessary so it gets approved? THAT is the language I need to see.

You are close. I think by next week you will see some determination and authorization your way.

I can see where they would want authorization number to process, that seems a norm anymore. Like you need a ticket to get into the show and a stub to get back in.

LOL LapDancer! I like that last quote

I went to my seminar yesterday, and although I knew much of it already I did get to meet the doctor, listen to him speak, and found out that he is much less strict than some others here on LPT... The lady who is his program coordinator was also his number #1 band patient 3 years ago, she is a walking testimonial, and I liked her because she pretty much told us like it is. Also one of his patients that got banded 6 months ago showed up to help answer any questions..... she and her husband got it done on the same day.......... oh and the insurance coordinator that I had been emailing was also there. It was really good for my dh to go too he learned alot.

What I noticed was a room FULL of people like me.. Obese. The looks on their faces were sad, embarrassed, depressed, and hopeless.... it really made an impact on me..... I wonder how many in the room will actually have the procedure.........

Some requirements from this doc........ pre-op 24 hours prior to surg. Clear liquids only.

Post-OP - 3 days full liquids, 5 days of creamy liquids, 1 week of purred foods.. about the time you go back for your 4 week check up he will try some solids.

He said the ONE thing you will have to give up is WHITE BREAD, because of the gluten.. (there was a lot of discussion on this) Basically Darlene explained it like this: take a piece of white bread, wad it up in a ball, and pour Water on it.... let it sit and then just watch how gummy it gets.. it acts like a cork... and either you will wait til it disapates or PB it up!

So when asked about how long til seminar to sugery.. he said about 4-6 weeks from time of insurance submittal (if you have everything they want) and about 2 weeks if your self pay.

I have my consult tomorrow, and I am SO glad that Darlene scheduled me for Monday, because yesterday they were scheduling appointments the last week of january

HAPPY MONDAY.. I'm getting ready to head off to my consult! I'm excited. I put all my documentation into a binded folder, complete with dividers.... I'm hoping to blow them away.

I did get this back from BCBS this morning...... (I had emailed back thanking for all her help)

Tracy,

I am happy to help. Please let me know if you require any additional assistance.

Best wishes for success with your scheduled procedure!

Thanks,

Cindy

Supervisor, Health Care Services

Blue Cross Blue Shield

Had my consult yesterday.. Doc said he would dictate my letter and most likely everything would get submitted to insurance today.... the INS coord. said she'd call me and let me know. I plan to only give them a couple days (bcbs) before I start following up with Cindy.

Tracy you're on your way. Very close to be sure.

..........

My Appeal was denied. My next option is to go to the state review. I will, what have I got to lose?

I will speak to employee benefits tomorrow. Today is a sad day for me.

Good News and OK news….

My docs office was on hold with my insurance for 45 minutes!!!!!!

I do have to do 2 things…..

1) Phyc Eval with a Shrink

2) Nutritional Eval with a Nutritionist

The doctors office gave me the name of the Nutritionist that they always use, I called and left a message for her.

I called my company EAP to see if I could get a session with one of the Shrinks on the panel for this…. (THIS WOULD MEAN IT IS FREE)

I need a letter from the dr. (shrink) going over my mental health history, saying that I am stable, and am able to make my own health decisions.

She said once all this is done, they will submit to the insurance and get the approval letter………. I should be able to schedule surgery for about 7 weeks out.

THE GOOD NEWS IS: NO 6 MONTH DIET!!!!!!!!

OKKKKKKKKK

Pysc Eval scheduled for NEXT Wednesday 1/17/06, I had to make several calls to places on my insurance network... one place totally ticked me off.. they were all high and mighty said I needed a minimum of 3 sessions, tried to tell ME what my insurance would want. I told them they were mistaken and that I would call my next provider on my list.........

So the doc I did find, it is a one session 2 part meeting.. 1st in an interview and second is a pencil test. Said he should have results and letter to me by the 25th.......... cost of this is $200.00 but they are bcbs.

Just waiting for the nutritionist to get back to me!

P.S. I did call my company EAP plan. Unfortunately, they can't get involved with any letter writing.. so using them is out. (which is why I'm glad I went ahead and started calling places IN network)

The places that were accepting new patients were either booking into the middle of February, or very demanding... (I'll be using my Flex Spending Account for the eval)