BLUE CROSS RUN-AROUND

[Guest guest]

Cross posting to main DS list and DS Insurance Problems list, and an

edited version to Dr. Welker.

Boy, oh boy! I decided to try to get some answers from Blue Cross

today. (I've received my first letter of denial and have not yet sent an

appeal--been really busy!!) Anyway, here's what I wanted to find out:

1) My " denial " letter didn't exactly say they would NOT pay for the

DS. So, I wanted to talk to someone about the letter. 2) Would Blue

Cross pay for part of the surgery and I pay for the DS part?

Here's the relevant part of the letter:

Our Medical Advisor has reviewed your request as part of our

utilization review program. Through this program, we evaluate the

medical necessity of care and the setting in which care is provided.

Our physician advisor, Dr. , has determined that although

surgery for morbid obesity is appropriate, the medical necessity of a

malabsorptive procedure as requested is not established since there is

no documentation of outcome benefit to offset increased risk.....

When I telephoned " claims " at BC a few months ago and listed the

insurance codes for the DS, she said ALL BUT ONE were covered services.

My thought was that maybe, if I go ahead and have the DS, they'll pay

those parts and leave the other one (the DS part) for me to pay....

Damn! Trying to get a straight answer from ANYONE at BLUE CROSS is

impossible. I was on the phone (including on-hold time) for over an

hour and a half. First, I spoke with Customer Service (aka Claims) who

referred me to Nurse Kathy assigned to my case. She said she would send

my file back to an " outside " doctor who is " in this field " to have it

RECONSIDERED. I asked if this is the same as an appeal and she said

NO. I told her that I did not hold out much hope for success but she

said she'd call me Thursday or Friday.

Nurse Kathy said that the " outside " doc will attempt to contact my

surgeon by phone twice. If my surgeon does not return the calls, Blue

Cross will consider that the surgeon has nothing to add and will deny

the claim. I'm going to let Dr. Welker know about all this--just in

case the doc really calls.

When I asked about the possibility of Blue Cross paying for part of the

surgery and I pay for the DS part, she said I'd have to talk to Claims

(aka: Customer Service). So I then called Tara who says she cannot help

me because Claims are for AFTER the services have been rendered. She

said I need to talk to the Pre-Authorization Department (aka:

Utilization Management Dept). By the way, that the SAME office Nurse

Kathy is at!!!!!!

Miss Tara suggested that I have my surgeon submit a claim. Then we'd

know what they'll cover. I asked her how could he submit a claim if the

procedure had not been done yet. She never explained that one!!! Maybe

Dr. Welker will know what she's talking about.

She gave me another phone number to call (but I still just go the same

" know-nothing " offices. I speak to in Medical Care Management

(aka: Pre-Authorization Dept, aka: Utilization Management Dept.). She,

too, CANNOT give me an answer as to whether they will pay any part of a

potential claim but does remind me that Nurse Kathy has forwarded my

case to be RECONSIDERED.

After much prodding, I found out who the Doctor is that will be

" reconsidering " my case. She didn't know for sure, but either Dr.

Blickenstaff or Dr. Dixon. Haven't I heard of Blickenstaff before and

he denied someone's appeal?

Good night...tomorrow is another day!

~~ShirleyAnn

Pre-op Dr. Welker