Anthem BC/BS

amy4hr · 02-21-2007, 09:15 AM

My insurance will cover the procedure at 50% with a maxium coverage amount of $15000. I am curious if anyone has had a similar type of coverage and what your out of pocket actually turned out to be. My out of pocket maximum for the plan year is $2500, but curious to know what happens when the $15000 maximum coverage for WLS is filled. Also, I am curious to know what the difference has been in costs with those with insurance and those without and why.
Thank you in advance!
Amy

TracyinKS · 02-21-2007, 12:03 PM

Seems like insurance gets billed at about double the cost of self pay...

WHY? Because its a game.

lizrbit · 02-21-2007, 12:34 PM

hi!
ive got anthem blue cross blue shield too. My policy covered the surgery 100 percent, but i had trouble with the out of network reference for the office visits. Ive paid only about 200 dollars so far during the testing process (one for nutritionalist and abill from the sleep study) and i dont know how much of the office visits ill owe, but you know it might help to think of it like buying a car.
Im looking at it like that, like i have a new volkswagen beetle around my stomach!

amy4hr · 02-21-2007, 04:56 PM

Almost seems like the smart thing to do would be to self-pay and then submit the claim myself and save the money. I find it interesting that there is all this talk in the news/insurance industry about being a smart health care consumer, yet the insurance companies/doctors seem to make it very difficult for us to do that.

chubbola · 02-21-2007, 08:33 PM

i have anthem BCBS also...my policy pays for up to $20,000 of bariatric surgery, so i'm cutting it pretty close!
liz------why did you get denied?

amy4hr · 02-21-2007, 09:33 PM

Liz, I haven't been denied but I haven't started the approval process either. I haven't met with a surgeon yet, I am just trying to understand what my benefits are and how much I would actually end up spending out of pocket before I decide if I want to move forward. I thought maybe if someone had a similar plan as mine they might be able to give me a real answer as my insurance company isn't answering the question.

I recently read the average "insurance cost" is around $30000. If my out of pocket maximum is $2500, and the insurance states it will cover 50% up to a lifetime maximum of $15000, who is paying for the $12500 difference? Am I expected to come up with that difference? If I am expected to pay that much, I am thinking I might as well do self pay and them file the claim myself and be reimbursed. Does that make sense?

Have you already been approved? Did you complete 6 months of MD supervised diet?

Thanks!

mel07 · 02-21-2007, 09:37 PM

One of the things to keep in mind is that what the MD and hospital charge is different from the contracted rate for the insurance company. I have Anthem as well but it is a virginia plan. I initially paid out of pocket ( would not recommend doing that) Anyway, my dr charged me 3850 for his fees. I just got the EOB from my insurance and they paid him 1700 which is the contracted rate. So he owes me money :)

If you stay in network you have that advantage of the contracted rates that BCBS has .

Good luck!

lizrbit · 02-22-2007, 07:52 AM

I think thats the key for a significantly easier approval, to stay in network. My plan is Maine (where i live).
They offer Lap Band surgery in Maine but its a very new proceedure there. I found my surgeon online through a couple of searches. I liked his stats and the fact that hes licensed by the manufacturers of my lap band, to teach the proceedure to other drs helped on top of his stats.
I contacted his office, and found them extremely helpful. Your surgeons office staff includes people who handle insurance exclusively. They interact with them. They will tell you what the insurance will require as well as what the surgeon requires.
I had an exhaustive history of medically supervised diets and programs extending years, as well as obesity related injuries and surgeries.
It was my surgeons office who submitted my claims. The first denial was because the results for the tests i took that the insurance required had not come in yet. The surgeons office resubmitted my claim for me, then i was denied a second time but...i wasnt denied the surgery, i was denied the out of network referral because the surgery is offered in maine. My surgeons office resubmitted with the reasons i chose them, and it was approved. My office visits are likely out of pocket, and I have to tell you, to me, this is worth it. I found the best surgeon for me, im GRATEFUL to have this system in place, Im hopeful for a chance at living a life that didnt revolve around my obesity.
I was banded Feb 13, i had no bruising and very little pain. The first day it felt like i swollowed a football, but im one week and one day post op and im walking twice a day, riding a bicycle everywhere i go in town, im working on the job i contracted so that i could be here during the time to obtain the surgery, and i love it. Ive lost around thirty lbs pre op and still going.
This is an investment in yourself. Ive bought cars for more that i was less invested in. Im not done yet either. if i get the weight off and sustain a year, i plan on cosmetic surgery as well.
I freaked on the insurance initially too, i called repeatedly and even requested a case manager and even though i think quite highly of my insurance plan, the surgeons office you go to, will definitely help you get through the red tape. They are used to dealing with insurance and they know what each specific insurance is looking for. They help with the entire process.
I would advise you to call your surgeons office if youve chosen one, if not, you can google "lap band surgery" in your state or area and find a service like JourneyLite to contact. It really does help sort it out. If you go to your insurances website, you can download the policy specificly to find what their requirements for lap band surgery are. I would not recommend self pay if you have insurance.
One thing they will ask you to do, is to find out if your insurance policy has a exclusion policy regarding gastric banding surgery. IF YOUR POLICY DOES, then you cant do anything about that and neither can the insurance company because that is the way the policy was set up through your employer! IF that is the case, then the surgeons office will have literature for self pay in terms of financing programs through loan companies and credit services, and ive even heard of people changing insurance in order to do it. If my insurance would not have covered this, i would have exhausted any avenue possible.
Im very hopeful this will work for me.

HelenC · 02-22-2007, 10:12 AM

I've got BC/BS of Illinois, and they covered my surgery 100% after my $300 deductible, and my fills are also at 100% with no copay (just found that out today *happy dance*).

I just don't understand all the discrepancies between the various Blues.

Candle · 02-22-2007, 11:44 AM

As I posted in your other thread - I have Anthem as well but there's an exclusion in my policy so they cover nothing

The first 2x I called Anthem they told me they DID cover the band then when I called to get details on requirements and if I needed the 6 month diet, they finally got it right and told me I'm NOT covered.

Make sure you give them the CPT code and get a definite "YES, you are covered."

Good luck

amy4hr · 02-23-2007, 10:38 AM

Where/How do I find the CPT code?
Thanks!

MEW · 02-23-2007, 01:32 PM

Quote:

Originally Posted by amy4hr

Where/How do I find the CPT code?
Thanks!

Check out this link amy:

http://www.lapbandtalk.com/new-cpt-codes-t11845.html

Adumont75 · 02-23-2007, 01:54 PM

I had my procedure scheduled for 4/2/07 as we awaited approval from ins. company. I was told today by my surgeons office that the insurance will only cover the procedure with a six month documented weight loss program through the MD's office. I am sooooo disappointed but I guess things happen for a reason and now I just have more time to prepare for the lifestyle change while attempting to drop some weight in the process. Has this happened to anyone else??

amy4hr · 02-23-2007, 03:54 PM

Quote:

Originally Posted by MEW

Check out this link amy:

http://www.lapbandtalk.com/new-cpt-codes-t11845.html

Thanks Mary!

Fluffy · 04-26-2007, 02:04 PM

Quote:

Originally Posted by Adumont75

I had my procedure scheduled for 4/2/07 as we awaited approval from ins. company. I was told today by my surgeons office that the insurance will only cover the procedure with a six month documented weight loss program through the MD's office. I am sooooo disappointed but I guess things happen for a reason and now I just have more time to prepare for the lifestyle change while attempting to drop some weight in the process. Has this happened to anyone else??

I was scheduled for May 10th and now that was cancelled until they hear back that I am approved. I have BCBSIL. I called the ins co and they said it takes 7 business days but that they have NOT received anything from the Lap Band coordinator to approve. So I called back the surgery center and asked why and they said that they're waiting for the psych eval to come back before they can send in all the stuff. Well, the psychologist told me I was approved by him and he'd get it typed up that day. That was on the 16th. So I am just really annoyed right now. I REALLY wanted the 10th to be the date but now even if it all gets approved fast they have cancelled the 10th and will have to reschedule at the soonest on the 17th. I AM SOOOOO DISAPPOINTED.

What I want to ask those of you with BCBS of IL is if you got approved without have a medically supervised diet plan documented. I meet EVERY criteria and then some and have tried every diet known to man, but the only thing I ever did medically supervised was Meridia. My doctor has been my doctor since 2000 and of course has my medical problems and obesity documented so that should be really good.

THOUGHTS??

We tried to do medically supervised dieting but my ins at that time wouldn't pay for it so, we just did all kinds of other things (nutrisystem and all kinds of crap).