Re: ins.: was;I also need revision surgery

July 27, 2003

> BCBS Fed is one of the ones who won't pre-approve the original surgery;

you have it done, submit the bills and hope they pay. They do if you meet

the criteria, etc., but a lot of stress and worry while waiting to see if

they pay and then HOW MUCH they pay.

**insurance companies are constantly coming up with new criteria, new hoops

to jump and thinking of any way to delay and deny paying for some

procedures. about every 2-3weeks we see a new trend at our office. the

trend for June additional documentation required showing a medically

supervised weight loss program for 6mo. duration in the last year. I can't

tell you how many patients had this come up prior to approval on various

different insurances. July's trend has been to require a full thyroid

panel. and just this past week we are getting a 3 page list of 15questions

that has to be answered which initially takes about 2hrs. and then

resubmitted before any precert action will take place. it too includes a

full thyroid panel but now they are focusing on the surgeons practice - they

want to know if support groups, education classes, etc. are offered. what is

the followup like. what percent of complications. what success rate. and

the list goes on. right now its Cigna who is using this new 15question

determination sheet. but they won't take a tsh, they want a full thyroid

panel and most doctors don't even do a full panel because insurance won't

pay. its a real catch 22.

but anyhow, the industry is constantly changing and trying to complicate

things. even without an exclusion they still don't want to pay or approve

procedures.

we have just submitted our first two precerts for the adjustable gastric

band - I'm anxious to see if they will pay for it or not.

sue

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