Re: DENIED AFTER SURGERY

[Guest guest]

Hi Gobo,

Thanks to Judi in Miss' help I am now working w/ the people in Wash

DC. It's gone from bad to worse w/ the OR office. Dr 's

office sent the corrected rebill on 4/13. On 4/24 I sent an online e-

mail inquiry asking the status of my corrected rebill and supplying

some names and dates of other BCBS FEP members who had our exact same

surgery.

On 4/26 they wrote a letter saying it was still being denied as E&O.

They never looked at the files of the people I told them about and

they said THEY NEVER RECEIVED THE CORRECTED REBILL. That means they

denied it again based on my 2 paragraph online inquiry! Wait, it gets

worse. I got my letter of denial w/ appeal info. They are now telling

me to appeal directly to OPM. They took my 2 paragraph online e-mail

inquiry as my APPEAL to them. They are the BIGGEST BUNCH OF ASS@#$%

S!!!! When I asked about the list of names they told me " You didn't

have gastric bypass surgery and those people didn't have the same

surgery as you " . IMAGINE the nerve!

I wrote all this to the Senior VP in Wash DC. I really hope something

is done about their cavalier attitude. I'll keep you posted.

-- In duodenalswitch@y..., " gobo " wrote:

> Hi ~

> Sorry to hear that Fed. BC is jerking you around!.They're trying to

> get away with something because they think they can, not

> because it's the appropriate thing to do.

>

> Absolutely, past cases where they have paid for the surgery will

> strengthen your case. By presenting examples of previous

> surgeries that were paid, you are demonstrating to BC that they

> are discriminating against you. That is one thing the Federal

> Government is very sensitive about. This will work in your favor.

> Another thing that works to your benefit is that since this is

> 'FEDERAL' insurance the coverage is the same no matter what

> state one lives in.

>

> If you look on ObesityHelp.com, there are statements from

> people who have successfully used Fed. BC. There also is one

> the group OSSG:Welker. It's listed under 'files', then you go to a

> file that says something about 'Insurance Companies that have

> paid for the DS'. If you need some help, email me.

>

> Finally, if you get to your wit's end, you can always call OPM. I

had

> to resort to that once. I spoke with the Contract Administrator for

> Blue Cross. You can bet that your local BC office sits up and

> listens when they get a call from the Blue Cross office in

> Washington, D.C.

>

> By the way, what was their 'official' explanation on the EOB when

> they turned it down the second time? Sometimes a bill is turned

> down due to an honest mistake. That's happened to me and a

> phone call takes care of the problem.

>

> Let me know about BOTH EOB's. It's important to know if they are

> the exact same explanation. If the explanations are the same, I

> believe that would be good news because they can not treat two

> distinctly different bills (different CPT codes) the same. If not,

> how are they different? I guess I forgot to mention that I also

have

> Federal Blue Cross. In addition, I worked in a hospital, dealing

> with insurance every day for 8 years and I once was a licensed

> health insurance agent.

>

> Good luck, and hugs to you,

> gobo

> DS pre-op, Dr.

> BMI 56

>

> " Sometimes We Never Know How We Influence the Lives of

> Others, Yet We Touch Those Lives Just the Same "

>

>

> > Hi All,

> >

> > I have BCBS Federal insurance who does not pre-authorize

> prior to

> > surgery.(Sometimes) In our plan book it states " Gastric bypass

> > surgery or gastric stapling procedures for morbid obesity " are

> > covered.

> >

> > I know of at least 18 patients w/ the same insurance that they

> have

> > paid for the DS for. My surgery was initially billed under an

> > unlisted code and the op notes were requested. They denied

> my surgery

> > saying it was experimental and investigational. I finally got my

> Dr's

> > office to send in a corrected rebill using 43633 and 43847 but

> the

> > damage was already done and I found out yesterday that they

> denied it

> > again.

> > I now have 2 levels of appeal. To the Oregon BCBS Fed and

> then to

> > Wash DC. Office of Personnel Mgmt.

> >

> > 2 Questions for y'all. 1. Is our surgery a " gastric bypass or

> gastric

> > stapling procedure " ? 2.Do they have to pay for my DS if they

> paid for

> > other MO patients? (historical precedent?)

> >

> > As you can well imagine I'm terrified at this stage. The thought

> of

> > 30k in bills is just so overwhelming.

> >

> > Any thoughts or advice. Thanks.

> >

> >

> > Lap LG/DS

> > 1/23/01 Dr