Re: BCBS Federal - Gobo

[Guest guest]

;

WOW!!!

That is unbelievable! (Not you, I mean that a person should have

to go through so much stress) ;-}

In a way, what you've gone through worries me that Dr.

will just say, 'to heck with it'. However, she IS a 'Preferred

Provider' for BCBS.

I don't know what office you're referring to in Chicago. In fact, I

can't think of any that would have anything to do with the Oregeon

BCBS. Up until now, I've only had problems with Mail Order Rx

(we're talking BIG time problems on more than one occasion).

Anyway, when I've had those problems, BCBS has been just as

uncooperative and ignorant as they've been with you. So, I called

OPM and within 24 hours they had read BCBS the 'riot act' and I

was getting phone calls of appologies and my 'missing meds'

delivered within 24 hours by Fedex (at their expense).

When Fed BCBS of Oregon said this is E&I, I challenged them

on that (what WAS I thinking?). Anyway, they said that they were

just telling me what Washington D.C. told them to say. I told

them I wanted the toll free phone number of Washington D.C.

They gave me the number for OPM. I was promptly forwarded to

the BCBS contract specialist and was 'generally' told not to worry

about what BCBS of Oregon told me. This man basically told me

what I already know to be true; that insurance companies will tell

a person anything and count on them believing it. He did not

come right out and bad mouth them to be sure, but he made it

clear that OPM is essentially on the side of the members of the

federal plan.

Now, is it possible that he's doing the same thing they are from

the opposite direction? Certainly, but that's not been my

experience. He said that they cannot get involved until the

member has appealed to them twice. Once you've been denied

three times (the first denial and then after two appeals) you

appeal to OPM. He said that the majority of members who

persist to the OPM level DO in fact prevail. He also said that if

BCBS is paying for the DS in SOME states, Oregon would be

hard pressed to allow them to deny.

The critical thing is that each state's BCBS administers its OWN

plan for federal employees. Thus, they act autonomously in

deciding what they will and won't pay. Once it gets to the OPM

level, the OPM looks at everyone equally, fair and square.

I guess my point is, if you have any problems, please be

encouraged by this info. I have names of people at OPM if you

need them.

Would you mind keeping me in your loop on how things go? I

have my second appointment with Dr. in 6 days and

hope to be switched within the month.

Thanks and hugs,

gobo

DS pre-op

Dr.

> Hi Gobo,

>

> I saw your post yesterday but didn't have enough time to

respond as I

> could write volumes about BCBS FEP.

>

> In June of 2000 BCBS FEP (officially) stopped pre-approving

WLS. They

> still will and this is key to a smooth benefit claim. Dr Welker,

> (since he had already written it up) faxed my LOMN to BCBS

and they

> said they never got it. So the Friday before my Tuesday surgery

> scrambling around trying to get precertified/preapproved. They

were

> less than accomodating. They said they would not take

anything out of

> order. They recommended changing my surgery date. We had

non-

> refundable airline tickets, my parents were coming to take care

of

> our kids etc. etc. I wasn't too concerned about BCBS paying for

my

> surgery because they had paid for 3 others out of the Oregon

office

> and another dozen (that I know of) across the country.

>

> A month or two after my surgery they tell me my surgery was

denied

> because it was E&I. Here are the reasons why it was denied

and the

> others were paid for:

>

> 1. No pre-approval. They say they don't but they do.

> 2. Dr 's biller used an " unlisted lap code for

abdominal

> surgery " 43659. Technically she is correct but the insurance

> companies will not acknowledge it. After 3 e-mails and a 3

page

> letter documenting the codes that every DS surgeon across the

country

> uses I got Dr 's office to REBILL using the usual and

> customary codes for DS.

> a.43847- gastric bypass w/ small bowel reconstruction to limit

> absorption.

> b.43633- partial gastrectomy

> 3. In the op notes Dr uses the term " Biliopancreatic

> Diversion w/ DS " . In the previous 3 DS surgeries that Oregon

paid for

> Dr Welker used the term " Lateral Gastrectomy w/ Duodenal

Switch " . He

> explained to me that when the insurance companies see the

term " BPD "

> they think of the old Scopinaro procedure w/o the DS. So w/ the

code

> 43659 and the term BPD/DS there were all sorts of red flags

raised.

> Lots of surgeons across the country still use the term BPD/DS

but

> they use it with the above codes so it usually goes through.

> 4. OFFICIALLY, the national BCBS FEP does consider the

LG/DS E&I.

> However many local plans go by their own their own state's

plans.

> i.e. I spoke to the BCBS FEP medical director for Nebraska

(thanks

> !) Dr Mellion. He says that the LG/DS is a covered

surgery

> and they DO NOT feel it's E&I.

>

> So, after my surgery was denied I started doing searches on

all the

> groups to see what I could find. I found Judi in MS posts and e-

> mailed her. We've talked many times and she put me in touch

with the

> home office in Wash. D.C. I wrote my first letter to the Senior VP

on

> 5/2. Each day they tell me I will have an answer. I REALLY

believe I

> will have an answer today. Here's what I've got thus far. They

are

> going to pay for my hospital, anesthesiologist and the " Gastric

> Restrictive " part of my sugeon's bill. I am working on getting

them

> to pay all of it. I have faxed them an inch thick of info regarding

> this surgery. Studies, Dr's websites info, and info on other

members

> who they have paid for previously (They ASSURED me that no

ones claim

> would be revoked that they have already paid for).

>

> The policies are not changed in Wash DC they are changed at

the

> Chicago office. Since this is such a big problem they should

just

> take it off the E&I list. That's what I'm hoping for!

>

> Gobo, in the mean time don't waste too much time with the

ignorant

> Oregon office. I loathe them. I wrote to the Oregon insurance

> commissioner regarding this matter and the BCBS Oregon

" lead " of

> customer service Sharon Meuicci wrote back to them saying:

" suffice

> it to say, Ms Leigh has not had the same surgery/procedure as

any

> other Federal Employee. "

> Their ignorance is only surpassed by their laziness.

>

> On the flip side the DC office has been great to work with

(albeit

> slow). I'll keep you posted. Hope this helps.

>

>

> Lap LG/DS Dr 1/23/01

> 268 BMI 42

> 197 BMI 31