Help - Insurance Riddle

[Guest guest]

Hello out there to everyone. I have a dilemma which others may share

or for which you might have heard about/can offer some advice. I

would appreciate your suggestions/comments directly to my email at

lavolpini@... so as to not tire everyone else on this list with

what may only be my problem. OK then - I have the Blue Shield Blue

Cross Federal Employee Plan. Its not an HMO - we can go to any

doctor. When I spoke with them about receiving Dr. R's letter, they

made it clear that as of June, the Fed Plan policy will not

preapprove

any surgeries but that all medically necessary surgeries are covered.

Why does this sound awfully suspicious to me? Apparently, I have to

just have the surgery and then submit the claim, which of course

they

can approve or deny. They insist, " If its medically necessary, we

will pay for it " . But hey, doesn't Dr. R's letters show solid

medical

necessity for all who meet the " published criteria " yet the insurance

companies still continue to deny claims? It is their interpretation

of

" medical necessity " that seems to continually change - by state, by

claims adjuster, by the mood swing of the adminstrator....In one way,

I feel that they are testing us (on my plan) daring me to have the

surgery yet never knowing if they'll pay. Maybe this is the way

they

weed out 'cosmetic surgery " seekers - by showing patient committment

come approval or denial. But, this is taking a huge financial risk

and I would rather fight with them before, rather than after the

fact.

Another wrinkle in all of this is that they say they will pre-certify

my hospital stay but not until they are requested for a surgery date

from Dr. R. Realistically, how can they precert the hospital and

not

the surgery? Isn't it implied? No they insisted....its not. Am I

missing something here? So gentle readers - any wisdom on this for

me? I don't post much on this message board but I am an avid - nay,

compulsive reader of these messages - every night before I go to

bed.Haven't missed a one since July 29 when I first signed on and

sent

in my Patient Info. Sweet dreams,