Can someone give me some advice? The doctor's office submitted my medical pre-assessment last fall to the insurance company (Blue Cross Blue Shield Federal Employees Plan). The doctor's office called me around Christmas saying: "Congratulations, you're pre-approved !!" At the time, I didn't get a copy of the letter the insurance sent but I have since gotten a copy after the surgery and it basically just reiterates the medical requirements. It never says I was "approved." So I had the surgery and now afterwards, the procedure has been disapproved twice. Based on the same exact medical information which was sent to the insurance prior to the surgery. I called them and they said it was because there is no evidence of two co-morbidities. (BMI was 39). The doctor's assessment documents: high cholesterol, hearburn (but not acid refux), depression not being treated, past infertility. I also have fatty liver but that does not appear to be in the pre-assessment. I also have acid reflux which was diagnosed prior to the surgery but after the pre-assessment was sent in. I am facing more than $40,000 in charges including the hospital. Here are my questions:

(1) should I get an insurance advocate to help me with this?

(2) isn't the doctor's office at fault here for telling me this was pre-approved and it really wasn't?

(3) isn't the insurance company at fault for having the medical information prior to the surgery and at least telling me they didn't think I met the qualifications at that time? (instead of sending a form letter?)

(4) what should I do next? any other thoughts, advice?

I would first ask your doctors office for the letter that shows you were approved. If no letter, they should keep some type of documentation of who they spoke to BCBS and when. If not, I would really question their eithics.

Has the doctor been paid? Is it the insurance company that is wanting money from you or the doctor?

$40k is not chump change and I would at least seek consulation from someone qualified in this area. It would seem to me that the doctor would NOT have gone through the surgery unless he though the insurance company was going to pay him, or unless you have already paid him in full.

Therefore, it sounds like a blunder on the insurance company's part. I just cannot see a doctor performing a surgery without getting paid by you or an insurance company stating they were going to pay for it, in some type of writing or letter.

I would first ask them if they received a letter from the insurance company and then go from there.

www.obesitylaw.com

I had a similar issue with BCBS. They flat out approved me for surgery, they knew I was going out of state. They said they would pay 70% of the approved cost of surgery. I said what is the approved cost of surgery, she fought me giving me a number, but I wouldn't let go...she said usually $10,000, so we'd pay $7,000 and you'd pay the balance.

After surgery, I found out I had a hiatal hernia repair (add 4,500) that was denied repeatedly by BCBS because it was not "preapproved" - and my doc said she didn't even know I had one - *I* never knew I had one - until she opened me up. One stitch: $4500. God I'm in the wrong line of business.

Anyway, to add further insult to injury, BCBS claimed that the "approved" cost for Lap Band surgery was $1400. ?!?!?!?!?!?!!?

They sent me a check for $1k and waved.

I harassed the hell out of them, resubmitted 5 times, the doc's office was outraged, they had called BCBS and were told I was approved for surgery at their out of network facility, same thing...never changed.

They had to send my account to collections. I was horrified.

Obesity Law said unless I could get a tape recording of the conversation it was a hard long process.

It was worth it for me in the end, mostly self pay, but $40,000 is a lot to swallow. I would definitely, DEFINITELY, get a lawyer who specializes in this.

Incidentally, Dr. Ren (my doctor) operated on Muhammad Ali's daughter, they wrote a book about her weight loss. Dr. Ren told me she had BCBS of Philadelphia (where I'm from) and the girl had to write an 80 page letter the BCBS to get them to approve her surgery. Yet they denied mine. It's complete bullcrap.

Fight!

I would contact your states insurance commisioner, that is where you need to start, let them advise you from there. I happen to know that fep does pay for the lapband surgery.

I would also go back to your primary physician and talk to him about co morbidities. See if he will go to bat for you with BCBS and help you document your reflux and any other problems stemming from your weight. My physician did a thorough interview documentin knee and joint pain, GERD, slightly elevated BP and cholesterol levels, and I was reimbursed quickly for my surgery in Mexico from FEP-BCBS.

I too have Federal BCBS and had surgery May 7th. I did receive an letter of "approval" before surgery, but now am wondering if it was not really an "approval" after all. You have me worried.

When did you have your surgery? I had a BMI of 37 but with severe reflux, back pain, joint pain, etc.

He also repaired a large hiatal hernia on me too.

Keep me posted. I will be anxious to see how we both fare.........

These seems to be something wrong with what your doctor says and what the insurance says. The doctor must have the documentation. I agree that he wouldn't perform the surgery unless he knows that he will get paid. I think you need to get an attorney anyway. Either to fight the insurance company or the doctor.

I agree it lies with the doctor's office. Doctor offices are first and foremost concerned with payment. They NEVER would have operated if you hadn't been approved. Someone in that office can help you. Otherwise, hire an advocate unless you are great with negotiation. Your surgeon should write off all charges...if it was performed at a hospital, that is another fight...

Also, appeal, appeal, appeal, especially if they found a hernia to repair, that is undeniable.

Good luck!

Justmel1957: you should get a copy of the letter. My letter was simply a statement of benefits. It was written personally for me, nor did it guarantee anything. That is not pre-approval to me. I believe the doctor's office misled me. But I'm more worried about the hospital charge.

Can any of you recommend an attorney in Illinois? My husband and I have started looking but most say they don't deal with this issue (even if they say they deal with insurance law).

I also plan to call the ILlinois Insurance commission and the Office of Personnel Management (the federal office which handles FEP appeals)

I am in the process of gathering all my medical records. Should I try to get the doctors to write letters and how easy is that to do?

specific question for snowbird: (I'm so glad you didn't have trouble). What kind of documentation did your doctor submit exactly? Did he just say you had these things, did he produce blood tests, write a letter?

www.obesitylaw.com

I had a similar issue with BCBS. They flat out approved me for surgery, they knew I was going out of state. They said they would pay 70% of the approved cost of surgery. I said what is the approved cost of surgery, she fought me giving me a number, but I wouldn't let go...she said usually $10,000, so we'd pay $7,000 and you'd pay the balance.

After surgery, I found out I had a hiatal hernia repair (add 4,500) that was denied repeatedly by BCBS because it was not "preapproved" - and my doc said she didn't even know I had one - *I* never knew I had one - until she opened me up. One stitch: $4500. God I'm in the wrong line of business.

Anyway, to add further insult to injury, BCBS claimed that the "approved" cost for Lap Band surgery was $1400. ?!?!?!?!?!?!!?

They sent me a check for $1k and waved.

I harassed the hell out of them, resubmitted 5 times, the doc's office was outraged, they had called BCBS and were told I was approved for surgery at their out of network facility, same thing...never changed.

They had to send my account to collections. I was horrified.

Obesity Law said unless I could get a tape recording of the conversation it was a hard long process.

It was worth it for me in the end, mostly self pay, but $40,000 is a lot to swallow. I would definitely, DEFINITELY, get a lawyer who specializes in this.

Incidentally, Dr. Ren (my doctor) operated on Muhammad Ali's daughter, they wrote a book about her weight loss. Dr. Ren told me she had BCBS of Philadelphia (where I'm from) and the girl had to write an 80 page letter the BCBS to get them to approve her surgery. Yet they denied mine. It's complete bullcrap.

Fight!

Dear Kate:

I'm sorry you had to go through all that but I'm glad it was worth it--100 pounds is so awesome. Let me ask you this: did you think obesity law was helpful ? I checked out their website and am considering contacting them. They say their success rate on overturning denials is greater than 90 percent. ???