Shocking news: I'm "pre-certified" but not "approved" for insurance

[Maggie Journey 126]

I got a phone call from my surgeon's office earlier this evening saying that my insurance company is covering my hernia repair, but NOT MY VSG. I went through this conversation with the surgeon's office a week ago. I knew it had to be wrong and someone was mixed up. I called to check pre-cert myself, and they assured me that I was "approved" for all of it. So tonight, after I'm hearing this from the surgeon's office yet again, I call my insurance company again and speak with benefits. They tell me (for the first time) that my policy does not cover bariatric surgery. I tell her that I've spoken twice recently with customer service and pre-certification, and they said that I am approved for surgery. She says yes, you are approved, because you have medical necessity. I ask again.... you are telling me that I am approved for surgery because of medical necessity, but my insurance is not covering it? What does that mean?? She just keeps repeating that my policy does not cover bariatric surgery. I ask her, how is one department at BCBS looking at my file and telling me I'm all set (approved), and then speak with another and I'm not covered???? Nothing. I'm stunned beyond all belief.

I've invested 7 months into this. After being "approved" by my insurance coverage, I was scheduled for surgery on 5/16, just six days from now. I'm deep into a 2-week all liquid only pre-op (the worst kind). I have pre-op labs and doctor appointments tomorrow. And I SUDDENLY might be self-pay.

Dr's office is telling me that my doctor is looking into the finance department to see about getting financing for me to do the VSG portion/surgeon's fee. The rest would be covered by insurance under the hernia repair. As of tonight, I have no idea how much that VSG portion will cost. As of right now, I don't even know if I'm going forward with it. I cannot believe I've invested so much of my time, energy, money and emotions into this, only to learn SO LATE that I'm not covered for this.

I am positive that at the very beginning, when I first went to the informational session last fall, filled out the paperwork and got a call the very next day from the surgeon's office: they told me that my insurance company would cover my VSG. I would not have even begun this process, let alone go this far, unless I was sure.

[KristenLe 5,980]

I'm not impressed with my BCBS Customer Service either. Do you have a copy of your Policy / Covered Services? I would call and speak to a Manager. Have them look back at the documentation of previous calls to see what you were original told. This blows. Hope you get it taken care of.

[scampbell33 88]

I got a phone call from my surgeon's office earlier this evening saying that my insurance company is covering my hernia repair, but NOT MY VSG. I went through this conversation with the surgeon's office a week ago. I knew it had to be wrong and someone was mixed up. I called to check pre-cert myself, and they assured me that I was "approved" for all of it. So tonight, after I'm hearing this from the surgeon's office yet again, I call my insurance company again and speak with benefits. They tell me (for the first time) that my policy does not cover bariatric surgery. I tell her that I've spoken twice recently with customer service and pre-certification, and they said that I am approved for surgery. She says yes, you are approved, because you have medical necessity. I ask again.... you are telling me that I am approved for surgery because of medical necessity, but my insurance is not covering it? What does that mean?? She just keeps repeating that my policy does not cover bariatric surgery. I ask her, how is one department at BCBS looking at my file and telling me I'm all set (approved), and then speak with another and I'm not covered???? Nothing. I'm stunned beyond all belief.

I've invested 7 months into this. After being "approved" by my insurance coverage, I was scheduled for surgery on 5/16, just six days from now. I'm deep into a 2-week all liquid only pre-op (the worst kind). I have pre-op labs and doctor appointments tomorrow. And I SUDDENLY might be self-pay.

Dr's office is telling me that my doctor is looking into the finance department to see about getting financing for me to do the VSG portion/surgeon's fee. The rest would be covered by insurance under the hernia repair. As of tonight, I have no idea how much that VSG portion will cost. As of right now, I don't even know if I'm going forward with it. I cannot believe I've invested so much of my time, energy, money and emotions into this, only to learn SO LATE that I'm not covered for this.

I am positive that at the very beginning, when I first went to the informational session last fall, filled out the paperwork and got a call the very next day from the surgeon's office: they told me that my insurance company would cover my VSG. I would not have even begun this process, let alone go this far, unless I was sure.

Me reading this, just made we want to tell u to be encouraged u have come this far to not give up now.... I too was challenged w my insurance 3 days before my surgery, and now I'm 8 days post op. What I'm saying Is , keep praying, keep believing, and stay focused.... and even if they push your surgery date back, you're still good... I've invested over a years time in preparing for this... so when this challenge came, it was like "oh no you won't either".... so continue to fight this good fight for your health...

Sent from my SAMSUNG-SM-G900A using the BariatricPal App

[kmorri 1,689]

@@Maggie Journey OMG Maggie! You've got to be kidding.....let me try to help you the best I can. I retired from BCBS of Florida in September......I see you're in GA so I assume it BCBS of GA.....if you'll send me a private message with your group number I'll see if I can get my hands on the medical policy......I need your "group" number not your member number. I'm so sorry this is happening to you!!!

[Christinamo7 4,042]

I am hoping and praying you can get some help and get this resolved. And it is time for insurance to start covering the one thing that has a good chance at helping with obesity issues.

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[Maggie Journey 126]

Me reading this, just made we want to tell u to be encouraged u have come this far to not give up now.... I too was challenged w my insurance 3 days before my surgery, and now I'm 8 days post op. What I'm saying Is , keep praying, keep believing, and stay focused.... and even if they push your surgery date back, you're still good... I've invested over a years time in preparing for this... so when this challenge came, it was like "oh no you won't either".... so continue to fight this good fight for your health...

Sent from my SAMSUNG-SM-G900A using the BariatricPal App

@@scampbell33, did your insurance fail you, or did you fight it and win? What happened? Thanks for the encouragement.

[kmorri 1,689]

Here's a link to BCBS of GA's medical policy. Do you know if your individual plan has an exclusion for Bariatric Surgery?

https://www.bcbsga.com/medicalpolicies/policies/mp_pw_a053317.htm

[Maggie Journey 126]

Here's a link to BCBS of GA's medical policy. Do you know if your individual plan has an exclusion for Bariatric Surgery?

https://www.bcbsga.com/medicalpolicies/policies/mp_pw_a053317.htm

Not to my knowledge. If it did have an exclusion, wouldn't that have come up from the beginning?

[scampbell33 88]

Well what happened to me was my insurance said I failed to do something on my end... but long story short, I fought it, and I won! As u will too... @@Maggie Journey and from the looks of all the ppl reaching out you'll be set straight in no time.. ????

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[JT2018 11]

Going in I knew WLS was excluded from my UHC policy. My surgeons office told me that UHC would cover the portion to repair my hernia and gallbladder but not the VSG. My cash pay portion (just the sleeve part) will be about $7k.

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[OutsideMatchInside 10,166]

If you have to self pay on the VSG part, ask for them to bill you at the same rate they charge BCBS. My surgeon fees for my surgery as paid, not billed, was around $1000.

You live in state that does not consider bariatric surgery a necessity so no policy is going to include bariatric surgery unless they really just want to because they are not required to by law.

I'm sorry you are having this experience. BCBSIL was wonderful with my approval, and claims. They have excellent customer service. Not all the companies using the BCBS name are the same.

[kaitlynm 335]

You need to check with your employer whether they cover WLS. (Or whoever provides your insurance). They are the ones that determine what the insurance will cover. They also can change every January so what might be covered in 2015 may not be in 2016. If that is the case you can talk to HR to try and get an exception if you were already in the process of qualifying.

[Maggie Journey 126]

After more phone calls this morning, it turns out that I am not covered for bariatric by my employer-sponsored insurance plan. I can't believe I'm just learning this only 5 days before surgery. My BCBS of GA (Anthem) insurance covers it, approved it verbally and in writing, and my medical necessities/co-morbidities were proven with 6+ months of requirements I have fulfilled. It's only my employer that screwed me. It's somewhere in the fine print of the benefits. At my first informational meeting last fall with the surgeon, I filled out the paperwork with all my insurance info. They called me the very next day, happy to let me know that my insurance covers bariatric and we could get started on the process. I never felt a reason to question my approval or dig deeper. My company did change things at the first of the year. They are notorious for changing it constantly. I should have known to not trust them. I'm the kind of Type A person who us usually tedious to a fault about these things and follows up on everything; I rarely ever get caught with my pants down. This time, my pants are down around my ankles.

It's midday and I just got done with my pre-op labs. I'm seeing my doc for the pre-op appointment in less than one hour. That's when I'll (hopefully) find out how much the VSG portion of the surgery will cost me, whether they are providing the financing arrangement, etc. I really, really don't want to take on more debt, but I truly do have medical necessity and more than anything else, I want quality of life and health.

Thanks for listening, Maggie

[Maggie Journey 126]

On the bright side, at the lab appointment I'm down another 3 lbs, but BEST of all, my blood pressure was a perfect 120/70. That makes me incredibly happy. I'm still on 2 kinds of BP meds for now, but that's the best BP reading I've seen in a long time.

[Christinamo7 4,042]

please let us know how the rest of this goes. I am very sorry you are getting this shock right at the end.