Guest guest Posted May 3, 2001 Report Share Posted May 3, 2001 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 3, 2001 Report Share Posted May 3, 2001 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 3, 2001 Report Share Posted May 3, 2001 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 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 4, 2001 Report Share Posted May 4, 2001 , I'm so sorry you have to deal with all this red tape! I'll keep my eyes open for anything that I think might help you. Good luck and I'm sure things will work out in your appeals stage. Maybe it might not be a bad idea to contact an attorney. I know there is an address on obesityhelp.com of an attorney whose specialty is obesity issues. Best of luck, Angel --- leigh6x@... wrote: > 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 > > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 4, 2001 Report Share Posted May 4, 2001 , I'm so sorry you have to deal with all this red tape! I'll keep my eyes open for anything that I think might help you. Good luck and I'm sure things will work out in your appeals stage. Maybe it might not be a bad idea to contact an attorney. I know there is an address on obesityhelp.com of an attorney whose specialty is obesity issues. Best of luck, Angel --- leigh6x@... wrote: > 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 > > > ---------------------------------------------------------------------- > Quote Link to comment Share on other sites More sharing options...
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