Federal Blue Cross [Cross Post]

[Guest guest]

I am posting here, my answer to a private email.

I do not know which list the writer is on, so I am going to cross-post this.

I hope this serves to help de-mystify the business about Blue Cross denying the

DS.

I do not believe that the problem is with Blue Cross but with the lack of CPT

code.

In the absence of a CPT code, there are ways to circumvent this problem. The

solution

lies in coding the procedure according to a description of what is being done

rather

than coding according to a uniformed title (BPD/DS).

Please read:

Hi;

I believe that Dr. Gagner is confused.

My OWN surgeon, Dr. Emma did her fellowship under Dr. Gagner. That

means

that everything she learned about Bariatric Surgery, she learned from Dr.

Gagner.

However, she always makes it clear that 'Billing' and 'Insurance' are not part

of a

surgeon's area of expertise.

Dr. Gagner mentioned to you 'Fed/NY Blue Cross'.

There is no such thing as 'Federal-New York' Blue Cross.

Dr. Gagner is taking information that may or may not be true for the Statewide

New

York Blue Cross and combining it with information that I believe to be in error

about

FEDERAL Blue Cross.

Also, the Federal Blue Cross in your state at least tried to point you in the

right

direction. The billing would in fact go through the Federal Blue Cross office

that is

local to New York.

Please realize that this is not the same office as the State Blue Cross office

that is

located in New York.

Each state has Blue Cross of that particular state and also, the Federal Blue

Cross has

offices in that state. They are related only in name; not in policies, rules or

administration.

I myself live in the State of Washington but had my surgery in the Sate of

Oregon. I

fully understand what you tried to explain to me. The problem is that folks who

have

Federal Blue Cross keep getting mis-information because of the state-wide Blue

Cross.

Also, the Federal Blue Cross of New York would be hard pressed to try to deny

something that is covered in all other states. The reason is simple, Federal

Blue Cross

is a federal, nation-wide insurance policy. We all have the exact same policy.

Our

policies do not depend on what state we live in. One state cannot deny something

based on what Blue Cross for a particular state denies unless all Blue Cross in

all

states denies it.

Getting back to Dr. Gagner and his belief that it is not covered in New York: I

believe

that the problem lies in the way the procedure is coded. I believe that Blue

Cross (and

other insurance carriers) have a problem with " BPD/DS " .

Dr. now uses a long protracted procedure name. There are about 16

words

total in the name. It starts out with, DGB or, " Distal Gastric Bypass " . The

description

goes on and on.

Dr. Rabkin also does the DS using this description.

As far as I know, both Dr. Rabkin and Dr. get reimbursed for this

procedure.

The only difference is the way it is described to the insurance company for

billing

purposes. Medically, there is absolutely no difference in what surgery we get.

By the way, the fault is not so much with the insurance companies. I know that

surgeons' offices and thwarted patients would have us think otherwise. The

problem

is that there is yet to be an agreed upon CPT code for the DS itself. That is

something

that just is going to have to take time in happening. The ASBS is trying to see

this

happen.

This is the way I understand it.

If you go to a restaurant that has lots of fancy dinners and they are each

ordered by

an item number, that is fine, unless you want to order a fancy dinner that does

not

have a corresponding item number.

Let's say, you want something, but the only way to get it is to order each item

individually. You might say, " I'll have the steak, broiled medium-rare, sliced

very thin "

(for London Char-broiled); " I'll have a baked potato w/chives; peas; salad; . .

.. "

In other words, you might be able to STILL get exactly what you want but you

might

have to describe it in detail and order it a la carte.

Well, the BPD/DS is complex enough that there are acceptable surgical

descriptions

for this procedure that taken together, each have the requisite CPT codes.

I would pursue this further. I don't see the problem as being the insurance. We

have

one of the more liberal ones. The policy even says that 'gastric bypass' is a

covered

procedure. There is no disclaimer to exclude one procedure over another. Please

look

at page 41 of our Federal Policy Book.

If you need anymore help, please let me know.

By the way, I just reread your message and saw you were talking to Blue

Cross-The

Empire Plan. That doesn't sound like Federal Blue Cross to me. That sounds like

the

state-wide Blue Cross for New York. If you call your federal Blue Cross, ask

them for

the telephone number for FEDERAL BLUE CROSS in New York. This really is

different

than the state-wide plan. Here in Washington (state) there is a separate office

and

phone number for Blue Cross of Washington versus Federal Blue Cross for

Washington

residents.

I know this seems like hell but it is worth it. The problem you're having right

now is

with the surgeon's offices ignorance, not the insurance itself.

Good luck.

gobo