Bcbs

LynnOregon · June 14, 2008

Has anyone ever had this happen? I was approved for surgery; my surgeon is in network, etc. My surgery was last March. BCBS paid for the hospital, the anesthesiologist, and the upper GI. I spoke with BCBS every step of the way to make sure of coverage. I recently received a statement from BCBS saying that my surgeon is not covered. How could this be?

I am so confused.:confused2:

Thanks.

Papa-Bear · June 14, 2008

Don't know if this is the same situation, but could be. For me, I checked and my surgeon and the hospital were covered. My statement showed I needed to pay for the "backup" surgeon (or whatever they want to call him), as he was not in network. I called to complain as I had no idea who would be in the room with my surgeon. They replied and said that they would re-process. Sometimes evidently, if one of the surgeons, or the Anesthesiologist submits there claim before the main surgeon, they may deny. They put it back through and I have not heard back from them since, so assume all is fine. I would say call them. Threaten them. If you called previously and they said it was fine, and likely your surgeon did the same, it is probably just a book keeping error (hopefully).

Good luck,

Papa-Bear

Hadassah · June 14, 2008

Insurances r a pain, I am in the process with BCBS too, and I really hope to get approved, because my policy has to be renewed in November and if I am not approved before that date, I will lose all the $$ I have paid towards my deductible. I had to talk to them already regarding a claim they didn't want to pay, they were very nice and said that it was a mistake from them, I hope the same happens to you.

LynnOregon · June 14, 2008

Thanks for your feedback. Because my husband's company is self insured, we are going to request their help. What is so confusing is that we sent in all the documentation BCBS asked us to. They sent an approval letter to both my surgeon and me.

I spoke with a representative from BCBS right before my surgery too. We discussed everything and she said, "Have a good surgery."

The rejection of the claim states the service/expense is not covered under our plan. This does not make sense because it is covered and my surgery was approved as medically necessary.

My BMI was fluctuating between 38 and 39 at the time of surgery, although it was 40 when I started my most recent weight loss program. We submitted all co-morbid conditions. I had at least four.

This is all so frustrating. The surgeon's bill is over $8,000. I don't understand why BCBS won't cover my surgeon!

Hopefully, I will have answers soon and I will post them to the forum so that others will be aware of this possibility.

Thanks again

LynnOregon · June 17, 2008

Just a quick update: I spoke with hospital where I had my surgery today and the woman in billing told me that BCBS was notorious for excluding coverage for the surgeon after approval for surgery. She said that it usually takes months of appeals for them to finally cover the surgeon. So much for dotting all the I's and crossing the T's prior to surgery. Just because your surgery is approved verbally and in writing with BCBS, doesn't mean that you will not be appealing for coverage apparently. I am going to stay positive and think speedy resolution!

Cristay30 · June 18, 2008

I have UHC Choice Plus. I had the surgery done on May 20th. Checking my claims online just to see how much I would be paying with my co-insurance and it shows the total hospital bill it self was paid but the surgeons claim was denied. I was denied saying I don't have coverage for weight loss surgery under my plan....which is not true since I got the pre-approval on April 17th. So now I'm fighting it out with UHC.

di1138 · June 18, 2008

I have horizon BC & BS of NJ and always fight with them. I am sure your surgeon received approval from them. Call his office and get all the approval info and go back to BC BS. I really dont think the bs stands for blue shield!

LynnOregon · June 27, 2008

We had to get my husband's self insured company involved. Once the HR manager spoke to BCBS, they paid the claim. I am not sure why coverage of the surgeon was denied after approval.... but as I said, the woman in billing said that BCBS is notorious for this.

The other thing hard to believe is that someone without insurance coverage would have to pay $8,300. for the surgeon when BCBS only pays the surgeon $2800. This seems so unfair that ordinary people have to pay so much more because they do not have the negotiating power that BCBS has.