What does this mean to you? (BCBS)

ronwifey · 01-21-2008, 04:11 AM

I finally found what my insurance policy says about surgery:

"Gastric restrictive procedures, gastric malabsorptive
procedures, and combination restrictive and
malabsorptive procedures to treat morbid obesity –
a condition in which an individual has a Body Mass
Index (BMI) of 40 or more, or an individual with a
BMI of 35 or more with co-morbidities who has
failed conservative treatment; eligible members
must be age 18 or over. Benefits are also available
for diagnostic studies and a psychological
examination performed prior to the procedure to

determine if the patient is a candidate for the procedure."

It also states this"

Preferred: $100 copayment per
performing surgeon

Note:

If you receive the services of

a co-surgeon, you pay a second
$100 copayment for those services.
No additional copayment applies to
the services of assistant surgeons.
Participating/Non-participating:

You pay all charges"

This is the part that I don't understand......"Participating/Non-participating: You pay all charges." What the heck???? I searched for my Dr. on BCBS website under "find a Dr". And the Dr. said they accept BCBS. Is that what participating means?

Thnaks in advance for any help.

sunsett · 01-21-2008, 10:45 AM

Yes that is what participating means.

You always want to call your insurance company and the Dr's office to reconfirm that they are in network.

sharona · 02-17-2008, 08:49 PM

It means if your physician is not a participant of BC then you pay more

sharon:)

Blund · 02-17-2008, 10:03 PM

You'd better call BC. I have BC of California (PPO) and I think my policy reads the same way. My BC requires the procedure be done in a "Center of Expertise" so you want to make sure wherever you go is approved as one. I had the under 40 BMI so I had to be sure I had comorbidities listed and that the surgery center I'm using is approved. It was especially tricky because I have California BC, but live in Michigan.

I have to have a "pre-service review" but am lucky in that my surgery center has a bariatric coordinator who knows all the ins and outs of insurance. My BC card has a 800 ph # on the back specifically for pre-service review info.

Good luck.

Maybe....... Blue Cross Bull Sh!t?!!

ronwifey · 02-18-2008, 03:14 PM

My Dr.s office has an office manager that deals strictly with insurance companies and also knows the in's and out's, luckily!

I was APPROVED, YIPEE!

Blund · 02-18-2008, 08:46 PM

Good for you ronwifey! I'm trying not to make myself and my DH nuts waiting. I'm kind of concerned when things might happen (if approved), with spring break coming up. We plan to travel.

Apples2 · 02-18-2008, 09:47 PM

Congratulations, Ronwifey. I have a couple of months left b/4 papers get sent back in again for approval. (My dr. thought he could get me through in 3mo. but ins. co. requires 6). I am diligently trying to lose more pre-op weight. Was a little disappointed when I was denied after 3 mo. but dr.'s nurse assured me it was only a time thing. I bet you are relieved and anticipating your next steps. I am looking forward to being at the step. Take care and good luck.

sheba08 · 02-20-2008, 06:47 PM

i have a question,i called the lap band drs office today they told me i need to go on a 6 month diet from my diet,then get bk with them thats whata bcbs michigan said i have benifiets.so i really dont need to start anything with the lap band dr till i do the 6 month diet right?i cant really have any tests done 6 months ahead,so do u think i should see the lap band dr closer to the time im thru with the 6 month diet/how much should u lose?

Apples2 · 02-20-2008, 07:07 PM

Every insurance company and every lap band dr. have different requirements. All I can tell you is what was required of me. I went to the initial seminar where my surgeon gave us general info about the lap band and then had an open question answer session. Received questionnaire the same night, filled it out and sent it back to surgeon's office. My six mo. supervised diet started with my first visit with the surgeon. Each mo. I visit my surgeon to go over any questions and he documents my weight loss. After I meet the 6 mo required time, my surgeon's office will turn in all my paperwork to my insurance company.

The first two months into this process I met with the nutritionist, psych, had sleep apnea test and any other test that was required. Your doc might have different hoops for you to jump through and at different times throughout this process. I wish you luck. The six mo. seems endless at first...but not so bad. Gives you time to consider what you're getting yourself into.

fayezy · 02-20-2008, 07:40 PM

Hi everyone-
Iam also going thru the 6mo diet and dealing with BCBS of michigan. The coordinator at the surg. office is very proactive. She knows all the ins and outs for the insurance and very involved with my pcp. So the extra time is all good.

ronwifey · 02-20-2008, 09:55 PM

You would think that Blue Cross Blue Shield would have same requirements no matter what state and or Company you have it through. I mean BCBS is still BCBS.

snowbird · 02-20-2008, 10:06 PM

An Employer buys insurance from the insurance company, and they work out how much insurance they get for the price they pay. The employer can pick and choose what benefits to pay for to cover their employees. So while an employee of company A may have BCBS coverage for a particular medical service, company B may not have purchased that coverage and their employees would not have that benefit. Just because the same insurance company is providing the coverage does not mean that two separate employers necessarily purchased the same amount of coverage.

010308 · 03-06-2008, 02:43 AM

Quote:

Originally Posted by ronwifey

You would think that Blue Cross Blue Shield would have same requirements no matter what state and or Company you have it through. I mean BCBS is still BCBS.

This is actually not the case. The way I understand it Blue Cross Blue Shield is a governing entity... but the plans themselves are independent licensees. If you look at your id card you will probably find that it says this.

010308 · 03-06-2008, 02:55 AM

Quote:

Originally Posted by ronwifey

This is the part that I don't understand......"Participating/Non-participating: You pay all charges." What the heck????

I know you've already found out that your surgeon is covered, but I will respond to this portion of your post. This tells me that you are on a PPO plan. This is telling you that there is no coverage for the service unless you go to someone who is considered PPO for the service. A provider who is participating without having the Preferred Provider contract would not be covered, nor would a provider who has no contract at all. I think it is common for BCBS plans to require use of a Center of Excellence.

The facility where I had my surgery is one of only two in the state where I live. Unfortunately they were the closest at 90 miles from my home, and the insurance company did not allow for anybody outside of the network which they normally would for other services when there isn't someone within a closer radius. It's very frustrating to have to make a 180 mile round trip and miss a day of work every 4 weeks to go get a fill, and ironic that my insurance carrier and my employer are one in the same and forced me into this position. Now I'm just complaining!

010308 · 03-06-2008, 03:08 AM

P.S. You are one lucky guy to have benefits like those!!!!!!!!!!!!!!!!!!!!!