Blue shield of California (medical)

[fatmommy1808 8]

Frustrated!!! I'm almost done with my 6th month supervision weight in. I called blue shield to get some up to date requirements over the surgery to my surprise l was inform that after they review my case then l get put on a "waiting list" l was never informed over this.... I have been through this journey almost a year.... Don't want to give up ,but I'm very frustrated!!! Has anyone been through medical approval (California) Any advice is Welcomed

[2goldengirl 2,076]

No such thing as a waiting list. And Blue Shield doesn't require six months any longer. Once you meet criteria, surgeon submits surgical request to your medical group, and provided they submit everything they need to when the request is submitted, medical group has five business days to make a decision. The 5-day turnaround is the law in CA.

Here is a link to all of Blue Shield's medical policies. You'll find bariatric surgery under "B". It will download as a .pdf.

BTW, your PCP, your medical group, and your surgeon's office may not know that Blue Shield changed their policy effective July 31, 2015.

[la.pereira 0]

I have Blue Shield and am wanting to bypass their 3 month "waiting period" recommendation. In which they suggest that you take some time to think about whether you really want the surgery or not. However I have been researching and thinking about it for the last 4 years. So I want to write them a letter addressing that in case they try to deny me because of the waiting period. (Which of course they will try to).

Any suggestions?

[Trinn 139]

The written policy doesn't have a three month waiting period. It has a suggestion of a minimum of 3 nutritional visits, but everyone I've talked to at BSCA was very clear that there are no solid requirements. Look, they have really loosened up the policy. I was approved two months after my first NUT visit, less than three months after I attended the first information session. What they wanted was the medical info and clearances, and not a "really think about it" period.

If anyone has told you differently -- well, I'm going to be honest, some of the folks at my care provider's were so used to the six month timeline that they repeatedly insisted that *surely* BS was not going to approve me quickly with only two NUT visits. However, the BS reps repeatedly told me to just have them submit the pre-auth -- and that if they were confused, they should talk to the BS reps directly. And you know what? It *was* approved immediately.

And yes, my surgeon's office and NUT and other folks did not know the policy had changed, did not believe me, and kept looking for a secret checklist to follow. I had to print out and carry the written policy with me to reassure them. Advocate for yourself!

[2goldengirl 2,076]

I have Blue Shield and am wanting to bypass their 3 month "waiting period" recommendation. In which they suggest that you take some time to think about whether you really want the surgery or not. However I have been researching and thinking about it for the last 4 years. So I want to write them a letter addressing that in case they try to deny me because of the waiting period. (Which of course they will try to).

Any suggestions?

The three month period is SUGGESTED, not required, and no, not because you may not want the surgery - but for the surgeon to assure that you are sufficiently prepared for post-op life. If your surgeon is satisfied, no reason he or she can't get approval for surgery prior to three months after the initial consultation.

As an example, my surgeon does required that I see an RD and have a psych eval - Blue Shield no longer does. And he wants those done before the initial consult. I did my orientation class in September and will have my initial consult in December, attending support group in the meantime. Depending on his schedule, I could be scheduled in January, and he will be able to document that I've been getting preparation and education for three months prior to initial consult even happens. Blue Shield's policy appears to be specifically written to take into account that different surgeons have different requirements. Believe me, if the three month period were required, rather than suggested, the policy would say so (I once wrote policies for a health plan).

I hope this helps.

[Trinn 139]

Also, it's not your job to write to the insurer -- your care provider will submit the pre-auth request with all the documentation. Do not try to "write a letter" in advance of a denial. You just end up looking like you don't understand how the system works.

[la.pereira 0]

Oh thank y'all so much yeah it appears that my surgeons girls had no idea what was going on HOPEFULLY they don't also mess up my paperwork later on...yeesh!

And thanks for that too because writing a letter is a ton of work anyway! Haha

[la.pereira 0]

I have Blue Shield and am wanting to bypass their 3 month "waiting period" recommendation. In which they suggest that you take some time to think about whether you really want the surgery or not. However I have been researching and thinking about it for the last 4 years. So I want to write them a letter addressing that in case they try to deny me because of the waiting period. (Which of course they will try to).

Any suggestions?

The three month period is SUGGESTED, not required, and no, not because you may not want the surgery - but for the surgeon to assure that you are sufficiently prepared for post-op life. If your surgeon is satisfied, no reason he or she can't get approval for surgery prior to three months after the initial consultation.

As an example, my surgeon does required that I see an RD and have a psych eval - Blue Shield no longer does. And he wants those done before the initial consult. I did my orientation class in September and will have my initial consult in December, attending support group in the meantime. Depending on his schedule, I could be scheduled in January, and he will be able to document that I've been getting preparation and education for three months prior to initial consult even happens. Blue Shield's policy appears to be specifically written to take into account that different surgeons have different requirements. Believe me, if the three month period were required, rather than suggested, the policy would say so (I once wrote policies for a health plan).

I hope this helps.

That definitely helped! Question: I'm running into some Dr's saying that I need a referral to make an appointment with them..but I haven't had my consultation with the surgeon yet! I want to make my appointments now so I don't have to wait 2-3 weeks to see each specialist. (My surgeon wants me to see 6 different ones!) Any advice would be much appreciated. Thanks!

[Sharon1964 2,530]

You're just going to have to wait to see the surgeon first.

[2goldengirl 2,076]

Six different specialists? That's an awful lot. Your PCP ought to be able to provide some, or all, of the referrals. Ask your PCP's office if they'll be in touch with the surgeon's office and see what they can do. My surgeon's office needs to do the referrals for RD and psych, but that's the rule for my medical group.

[la.pereira 0]

Can someone translate this for me?

I take it as they want me to fail a diet before seeing my surgeon and bring them proof.

"Patients should have documented failure to respond to conservative measures for weight reduction prior to consideration of bariatric surgery"

[Trinn 139]

It means they'd like to see that a diet or medication or something didn't work. It does NOT mean that you have to have done that supervised for X months or something. So, for example, my surgeon and nutritionist took my history, where I explained that I had lost weight eating very low carb in the past, but I had gained it back, and found that I could not sustain that weight loss over time. I could give them dates of when I did that, and exactly how -- I used Diet-to-Go for food for a period of time, for example. They put that in my history. And then when they wrote the pre-auth documentation, they could say, ""Patient has a documented failure to respond to conservative measures for weight reduction; two separate attempts eventually led to weight regain..." and like that.

The point here is that when you meet with a surgeon, have that timeline in front of you. Write it down. Be ready to say, "From February-November 2006, I ate less than 20 gm carbs every day. I lost 50 lbs. However, I regained that weight starting during the holiday season. By the 2008, I weight 30 lbs more than before the weight loss..." Or whatever your narrative is for what you've done.

[Trinn 139]

I literally typed up my weight history with dates of when I knew I weighed particular amounts and brought it in with me to my initial consults with both my nutritionist and my surgeon. I gave them a copy for their records.

[la.pereira 0]

What insurance do y'all have?

Also...

My policy says both of the following:

-Description of non-surgical weight reduction program (weight watchers etc) initial weight, end weight, duration.

-Documented failure to respond to conservative measures for weight reduction ..etc etc etc

So could that be sort of combined? I've done multiple programs on my own and with companies like Weight Watchers. And I lost weight but always gained it back.

Edited November 20, 2015 by la.pereira

[Trinn 139]

This topic says "Blue Shield of California", so I am responding with the assumption that you and other posters have Blue Shield of California. If you have another insurance provider, this is not a good thread to ask your question.