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Bizarre... BCBS Federal



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So, my surgery was pre-approved. I had surgery on the day I was pre-approved for by the doc and at the hospital that was submitted for pre-approval. Hospital was paid. Doc was paid. A third doc was paid... it appears to be lab related, but I have no clue who it is. I can see all of this on the BCBS website. Today I get a letter stating that they (BCBS) have requested medical records from the doc listed below (but no doc is listed below). They state that it is to do a medical review of a service provided the same day as my surgery. They want all H&P documenting prior treatment and results and co-morbid conditions, current lab reports, height weight & BMI, copy of psychotherapy eval and documentation of participation in a weight loss program. To me that sounds like they are reviewing medical necessity of my surgery to pay either the surgeon or the hospital. But it was pre-approved and both were paid! (scratching head here) Besides the lab, the only other physician that may need to be paid is anesthesia, but it is weird that they would do a medical review of that claim. Then I go online to search for the Claim # to get more information... and nothing shows up! So stupid and frustrating. And this makes no sense. I guess I have 2 choices... wait and see how this plays out or call them. And I really don't want to call them lol. Anyone else have this sort of weirdness? I mean seriously, the hospital and surgeon have been paid according to their own claims records... what the heck?

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You've already had the surgery so just let it play out it's not your problem it's really between your insurance and the hospital :)

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25 minutes ago, Mikeyy said:

You've already had the surgery so just let it play out it's not your problem it's really between your insurance and the hospital :)

That is just it... I don't even think it has anything to do with the hospital, they have been paid! I just don't want to get hit with some crazy bill. I am leaning towards leaving it alone though for a bit... I wish I knew where this claim is coming from though so I can guestimate how bad it will be if I have to pay it or fight for them to pay it.

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Fight :)

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Maybe they pulled it for auditing? Like above posters...hang tight. I think insurance companies continually audit physicians, pharmacies etc. Let us know how it goes. If problems I believe your HR dept can get involved as administrators of your plan. It was all approved beforehand with documented conditions for medical necessity.

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I have BCBS Federal as well and got several pre-approval letters, did you save those? My initial letter was an approval for the sleeve on a date a month out from the approval date, then it was for the bypass because I have severe GERD on the date I chose for surgery, then yet another one for the bypass on the surgery date with the 2 days I stayed in the hospital. I saved all of them for this reason alone.

If I were you, I'd call your surgeon and let them know because if they had to submit all of that info for the pre-approval then they should still have it and it shouldn't be an issue. I had problems with insurance covering protonix and my surgeon was all over them to get it approved.

I'm currently fighting with the hospital and insurance because the insurance company has had to fix my copay twice for the hospital stay because the hospital has decided to add another line item to the original bill. It's a mess but I think I have it figured out, finally.

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Somehow I have no idea where the letter is... but the big bill is paid by insurance and even my explanation if benefits mentions preapproval. But the claim number isn't the hospital bill. That is why this is so strange! The only outstanding bill is anesthesia I think.

Sent from my SM-G955U using BariatricPal mobile app

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I have BCBS Federal and am wondering if anyone can tell me what their out of pocket ended up being. I’m just looking for a ballpark figure because I have absolutely no idea. I am a planner and feel a need to be prepared for the general number that comes up when I get to that point.

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Posted (edited)

My out of pocket costs were just under $1000. I made sure to find a blue distinction center knowing I was looking at 1-2 nights in the hospital. It made my hospital copay go from $350 to $200. The grand total is copays from the visits with my surgeon, primary, preop testing, psych evaluation, EGD, and the actual surgery.

I have the basic option BTW. I know with the standard your costs will be way more.

Edited by ahillig

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Thank you for the info!!

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