BCBS Federal - Gobo

[Guest guest]

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