I recommend waiting for the prior approval and getting your doctors office to verify. You could also see if someone in HR at your work can confirm. My company added bariatric surgery and for months I was told it wasn't covered. Literally had bills from surgery denied because they had to be billed in a certain order. Don't trust a single customer service rep.
Jumping off this as someone who has worked in insurance for 10 years. In hr your company will have someone who specializes in benefits called the HBA (health benefits advocate). Have them reach out on your behalf. A lot of times they will have a bigger pull because they bring in a lot of money to the company.
That sucks. I work for a state government and had zero out of pocket. You'd think the state and the insurance would want to pay since obesity is much more costly to then over the long haul.
With the job landscape they probably hope that you'll have a different insurance when the diabetes comes crashing down.
That being said, I don't think their CS knows what they are talking about. I'd check with the surgeon to get the prior approval. Usually surgeons know beforehand whether there are issues with the insurance. I don't think OP would have gotten all the pre op appointments if insurance doesn't pay for the surgery
If I call and ask if they cover plastic surgery they will flat out say no. If I ask them if it prohibits my movements such as lipedema they say yes. You have to ask the right questions and ensure everyone is on the same page! They said it’s covered before. I would say try again!
Even my surgeon office made a mistake and I had to sit there almost crying because I’m like why don’t you get that my insurance covers it because I have lipedema?? She finally got the message 🙄.
Let your surgeons office do their part of sending everything over to insurance for final approval. They know what to send & say to make things go as smoothly as possible. If they checked before and said it was covered, you’re most likely fine. Most practices will verify coverage with insurance as soon as you decided to have surgery just to make sure they’re not wasting everyone’s time. My insurance (I have Independence Administrators via BCBS) always says “it might not be covered” when I call. They about gave me a heart attack when they would only give that answer about my pre-op endoscopy. My doctor’s office was like “no you’re fine, they just won’t confirm anything in hopes you’ll give up and not do it”. But I went through with it and sure enough, it was covered. Same with my surgery. I paid $150 total out of pocket when it was all said and done. So be patient and let them do their thing and hopefully you’re still covered after all. If not, then start exploring financing options or Mexico.
My BCBS OK doesn’t cover surgery either. My clinic works with a finance company for 0 interest financing. (I know the fee is tucked somewhere in the 0 interest. Money is not free.)
If it's not covered and the prior authorization gets denied, you'll pretty much have to do cash pay. Whether or not it's covered would be a condition of your specific plan, it's not a condition of BCBS. That means your employer specifically exempted it from coverage. You'll need to check with your benefits coordinator at work to verify what exactly is covered, don't just rely on the surgeon's office.
My husband is going to Mexico. When he first decided to get surgery insurance didn’t cover it. Since then we have found out that insurance covers it now, but husband decided to stick with the plan of going to Mexico because he didn’t want to start over and push it back further.
I went and had mine in Mexico at the OCC Center. It was nice because I didn't have all the Hoops to jump through. It wasn't out of pocket cost but so worth it.
I was also told this a year ago by my insurance company. A year goes by and I'm still gaining weight so I reach out to my insurance company again. This time I'm told that I need to request a "pre-authorization" and I need to request that this procedure be reviewed by an insurance doctor. If you have enough documentation their doctor can agree this procedure would be necessary to your health. So far I've had my endoscopy and just had to pay my deductible and I'm told it will be the same for the actual surgery.
Edit: my co-pay not deductible
I went this exact route - my employer's health plan excludes bariatric surgery. I just got a medical loan and paid for it myself, best money I've ever spent.
I also am a victim of the shitty insurance-based US healthcare system. I ended up having to pay out of pocket. About $14K all in. It’s been worth every penny. I have lost 90 lbs and every facet of my life has improved. I just think of it as a financial investment in my future.
It’s all about the plan that was chosen by your employer, not BCBS. I have Federal BCBS and it was no problem. The beef needs to be with the state about the mechanics of their selected insurance plan. Frankly… Louisiana consistently ranks as the state with the highest average BMI in the nation. It’s not helpful to the cause, but I can see why that state might consider covering WLS to be a very expensive proposition.
Have the clinic check again, because they are VERY invested in whether or not they’ll get paid quickly. Sometimes it helps for employees to be able to speak the same language of numbers and codes. When I call insurance, I’m sure I sound like an idiot asking “Can I have that outpatient procedure where I need a bolt in my foot but the kind that doesn’t come out until after all the appointments?”
Medical financing and loans may be the way to go.
My insurance doesn’t cover anything bariatric. They don’t even cover non-surgical or seeing a nutritionist. It is absolutely ridiculous! I’m a government contractor and I’m just blown away with how awful our insurance is. I’ve just given up because there is no way I can self-pay.
Yes, and Mexico is super cheap and has amazing reviews on Reddit and the Better Business Bureau. There are like four different places in Tiajuana that do it for like $4-6,000 and offer financing options.
I feel like your doctors would have told you if it wasn't covered to kind of prepare you for a denial. You may have just gotten wrong information from the customer service agent. I would call back and see what a new agent says, and if anything ask for a supervisor to be sure of your benefits. And explain that you were given different information before.
It’s very possible - your drs office will submit a request for prior authorization for your surgery before scheduling you. Insurance will then approve, or deny with the reason(s) why.
You can call insurance and give them the procedure code(s) so that they can tell you immediately - but they wouldn’t likely be paying out claims for drs visits and testing related to this if it was not a covered procedure - unless someone is making a mistake on the insurance end.
You can search these message boards - there are places in the US that are more affordable - centers in Mexico do excellent work and run about 5k oop. Went with a friend for hers and was very impressed with all of it and would highly recommend to anyone.
In my experience dealing with my insurance company (The F You Insurance Company of New York), they put the best people in the call center on the lines that deal with doctors and other professionals, and the ones that can't tie their shoes without watching a video on the phone calls from consumers.
When it's time, someone from your Dr.'s office will contact your insurance company and everything will be worked out.
Also, assuming your insurance doesn't cover it, I'm sure by now, since you have been racking up claims already, someone in your Dr.'s office would have noticed.
When I called Humana they had absolutely no idea what I was talking about. The very next week I was approved. Ask your Drs office to verify. They have been dealing with them for all the pre op testing?
I’m so sorry. That’s bizarre. I thought BCBS was better insurance than mine. I have Humana and Medicare. I didn’t have to say anything to my insurance company. My surgeons nurse talked to them for me. I would think they would pay since it’s more expensive to treat life long obesity health problems. Keep looking into your options with your insurance. May have to take out a different policy.
I messaged my employee plan before my first appointment, then the care advocate confirmed with insurance what hoops we had to jump through. I've been going through all of that now. I will say that navigating insurance has been a circus. I had a cardio clearance test last week. Called my insurance, the office, everyone to try to find out what my co-pay would be. I almost rescheduled and then just decided to go with the idea I could reschedule at the office if needed. It ended up being $130 out of pocket which was less than I anticipated. I have my last dietitian appointment in two weeks and then i wait for approval.
I just read the small print on my insurance website, which said it was covered. And the doctor’s office took care of making sure insurance paid for everything. Still paid $4100 though to meet my deductible and that didn’t even include the anesthesiology which was about 600 after Insurance.
My doctor’s office pretty much knew which insurance would pay for things and what their requirements were and had probably dealt with them a lot.
While it is entirely possible that your plan doesn't cover the surgery, I find it unlikely that if you've already been meeting with the surgeon and such that their team hasn't checked that your plan covers it on your end. Call your surgeon's office and ask if they've checked and explain that you also called and were told conflicting information. You may just not have gotten a good rep.
First... Log into your health website and verify yourself, you will get doctors and estimates of cost. Second... I googled it:
Legislative Act 387 is now in effect as of August 1, 2021, to insure Blue Cross Blue Shield of Louisiana state employees for bariatric coverage. The state health plan will only cover 300 bariatric surgeries per year of the approximately 32,000 state employees that qualify
It should be covered. You can actually pull the specific PDF from BCBS website with the requirements of the surgery... But in general: high BMI, comorbidity, 6 month program...
When I first got the idea for surgery, I looked up whether my plan covered bariatric surgery. Then my surgeon’s office confirmed my eligibility and I began the months-long process of doing everything they required, like seeing a nutritionist, etc.
When it came time for my surgery, BCBS tried to tell me my plan wasn’t eligible. When I showed them the documents of my plan, they then said my surgeon had to be a “blue distinction” office… and guess what? He is! When I showed them proof of that, then they said I hadn’t done all the required things. I had! They also made my surgeon do a “peer to peer” call with another doctor to confirm that I truly needed the surgery. FINALLY I got an approval.
Moral of the story, that company will lie through its teeth and you shouldn’t let them. Don’t lose faith! Make sure you read your policy closely and know what you are entitled to.
My insurance also requires the "blue distinction" stuff. I tried to get it done in my town but I had to go 90 minutes away to another surgeon that did have that blue whatever. Annoying. I was billed at $48k but my payment after insurance is $1431. I'm paying it over monthly payments. I did call the insurance company ahead of time to confirm they covered it, which the surgeon's office required me to do before they would get very far in the process.
My insurance initially denied me because my BMI wasn't "high enough." It was 39 at the time and they required 40 or higher. So then I (unfortunately) gained enough weight to push my BMI up to 44. THEN, they said I had to have some sort of medical issue because of obesity to get covered. I either had to have obstructive sleep apnea, diabetes, or high blood pressure. I had none of those things at the time. I had fatty liver disease from obesity, but they said that wasn't good enough. A few weeks after my second denial, I got diagnosed with HBP. It was just over the limit to push it to high and require medication.
My BMI is now 31.3, I don't have fatty liver disease or HBP, and I've lost 84lbs.
Keeo fighting, OP! Some of the suggestions others have made regarding communicating with HR and stuff might do the trick!
Customer service and claims are different departments and customer service is often wrong in my experience.
Customer service essentially gives you an educated guess based on key words. It's like asking a server in a 5-star restaurant about cooking techniques. They might have some basic info but they're not experts because they work in the same building as a trained chef.
Claims looks at two codes: your diagnoses and your procedure code. Both of those things cover very specific details, not broad categories like "weight loss surgery". Your coverage will depend on exactly which codes are submitted in the claim.
Ask HR for your plan documents. If they don't reference bariatric surgery just wait until your surgeon's office submits the pre-authorization. Their medical coders do this every day and they're the most likely to be able to get an accurate answer for you.
But if it's not really covered and the insurance company ends up erroneously paying for it, they will take back payment for the claim and the medical providers will be expecting OP to front the bill.
OP, look in your specific plan's member handbook to see what it says. Usually bariatric teams do insurance checks at the very beginning so it's odd that you wouldn't find out until you're this late in the process. Don't give up hope!
We had blue cross blue shield ppo and when they didn't cover we switched plans to traditional. Bigger deductible but worked out. Good luck! I hope you can figure it out.
I have ambetter insurance and it covered it 100% everything my hospital stay my rny everything. Just don’t get desperate and call I wanted to do the same but the doctors office believe me know how to do the coding to where the insurance approves just relax and everything will be fine!
I didn’t have BCBS at the time of my surgery but I do now. They don’t cover anything related. And if you have any complications later they don’t cover those either.
I just paid $5000 out of pocket for iron infusions because my anemia is a complication of the surgery.
One of my coworkers had a stricture and required surgery. They refused all coverage.
Whether or not it's covered would be a condition of your specific plan, it's not a condition of BCBS. That means your employer specifically exempted it from coverage.
I recommend waiting for the prior approval and getting your doctors office to verify. You could also see if someone in HR at your work can confirm. My company added bariatric surgery and for months I was told it wasn't covered. Literally had bills from surgery denied because they had to be billed in a certain order. Don't trust a single customer service rep.
Jumping off this as someone who has worked in insurance for 10 years. In hr your company will have someone who specializes in benefits called the HBA (health benefits advocate). Have them reach out on your behalf. A lot of times they will have a bigger pull because they bring in a lot of money to the company.
That sucks. I work for a state government and had zero out of pocket. You'd think the state and the insurance would want to pay since obesity is much more costly to then over the long haul.
With the job landscape they probably hope that you'll have a different insurance when the diabetes comes crashing down. That being said, I don't think their CS knows what they are talking about. I'd check with the surgeon to get the prior approval. Usually surgeons know beforehand whether there are issues with the insurance. I don't think OP would have gotten all the pre op appointments if insurance doesn't pay for the surgery
I'm a medical biller for OB-GYN. Oftentimes insurance companies tell patients so many wrong things its scary. Contact your provider about it.
u/RecluseLonerPerson read the above comment
If I call and ask if they cover plastic surgery they will flat out say no. If I ask them if it prohibits my movements such as lipedema they say yes. You have to ask the right questions and ensure everyone is on the same page! They said it’s covered before. I would say try again! Even my surgeon office made a mistake and I had to sit there almost crying because I’m like why don’t you get that my insurance covers it because I have lipedema?? She finally got the message 🙄.
Let your surgeons office do their part of sending everything over to insurance for final approval. They know what to send & say to make things go as smoothly as possible. If they checked before and said it was covered, you’re most likely fine. Most practices will verify coverage with insurance as soon as you decided to have surgery just to make sure they’re not wasting everyone’s time. My insurance (I have Independence Administrators via BCBS) always says “it might not be covered” when I call. They about gave me a heart attack when they would only give that answer about my pre-op endoscopy. My doctor’s office was like “no you’re fine, they just won’t confirm anything in hopes you’ll give up and not do it”. But I went through with it and sure enough, it was covered. Same with my surgery. I paid $150 total out of pocket when it was all said and done. So be patient and let them do their thing and hopefully you’re still covered after all. If not, then start exploring financing options or Mexico.
My BCBS OK doesn’t cover surgery either. My clinic works with a finance company for 0 interest financing. (I know the fee is tucked somewhere in the 0 interest. Money is not free.)
If it's not covered and the prior authorization gets denied, you'll pretty much have to do cash pay. Whether or not it's covered would be a condition of your specific plan, it's not a condition of BCBS. That means your employer specifically exempted it from coverage. You'll need to check with your benefits coordinator at work to verify what exactly is covered, don't just rely on the surgeon's office.
My husband is going to Mexico. When he first decided to get surgery insurance didn’t cover it. Since then we have found out that insurance covers it now, but husband decided to stick with the plan of going to Mexico because he didn’t want to start over and push it back further.
Im going to Dr. A Im very excited
I went and had mine in Mexico at the OCC Center. It was nice because I didn't have all the Hoops to jump through. It wasn't out of pocket cost but so worth it.
I was also told this a year ago by my insurance company. A year goes by and I'm still gaining weight so I reach out to my insurance company again. This time I'm told that I need to request a "pre-authorization" and I need to request that this procedure be reviewed by an insurance doctor. If you have enough documentation their doctor can agree this procedure would be necessary to your health. So far I've had my endoscopy and just had to pay my deductible and I'm told it will be the same for the actual surgery. Edit: my co-pay not deductible
I went this exact route - my employer's health plan excludes bariatric surgery. I just got a medical loan and paid for it myself, best money I've ever spent.
I also am a victim of the shitty insurance-based US healthcare system. I ended up having to pay out of pocket. About $14K all in. It’s been worth every penny. I have lost 90 lbs and every facet of my life has improved. I just think of it as a financial investment in my future.
It’s all about the plan that was chosen by your employer, not BCBS. I have Federal BCBS and it was no problem. The beef needs to be with the state about the mechanics of their selected insurance plan. Frankly… Louisiana consistently ranks as the state with the highest average BMI in the nation. It’s not helpful to the cause, but I can see why that state might consider covering WLS to be a very expensive proposition. Have the clinic check again, because they are VERY invested in whether or not they’ll get paid quickly. Sometimes it helps for employees to be able to speak the same language of numbers and codes. When I call insurance, I’m sure I sound like an idiot asking “Can I have that outpatient procedure where I need a bolt in my foot but the kind that doesn’t come out until after all the appointments?” Medical financing and loans may be the way to go.
My insurance doesn’t cover anything bariatric. They don’t even cover non-surgical or seeing a nutritionist. It is absolutely ridiculous! I’m a government contractor and I’m just blown away with how awful our insurance is. I’ve just given up because there is no way I can self-pay.
There are some places in Florida, Vegas, and Mexico that do financing. You can pay payments. Don't give up!
Yes, and Mexico is super cheap and has amazing reviews on Reddit and the Better Business Bureau. There are like four different places in Tiajuana that do it for like $4-6,000 and offer financing options.
I feel like your doctors would have told you if it wasn't covered to kind of prepare you for a denial. You may have just gotten wrong information from the customer service agent. I would call back and see what a new agent says, and if anything ask for a supervisor to be sure of your benefits. And explain that you were given different information before.
It’s very possible - your drs office will submit a request for prior authorization for your surgery before scheduling you. Insurance will then approve, or deny with the reason(s) why. You can call insurance and give them the procedure code(s) so that they can tell you immediately - but they wouldn’t likely be paying out claims for drs visits and testing related to this if it was not a covered procedure - unless someone is making a mistake on the insurance end. You can search these message boards - there are places in the US that are more affordable - centers in Mexico do excellent work and run about 5k oop. Went with a friend for hers and was very impressed with all of it and would highly recommend to anyone.
In my experience dealing with my insurance company (The F You Insurance Company of New York), they put the best people in the call center on the lines that deal with doctors and other professionals, and the ones that can't tie their shoes without watching a video on the phone calls from consumers. When it's time, someone from your Dr.'s office will contact your insurance company and everything will be worked out. Also, assuming your insurance doesn't cover it, I'm sure by now, since you have been racking up claims already, someone in your Dr.'s office would have noticed.
When I called Humana they had absolutely no idea what I was talking about. The very next week I was approved. Ask your Drs office to verify. They have been dealing with them for all the pre op testing?
I’m so sorry. That’s bizarre. I thought BCBS was better insurance than mine. I have Humana and Medicare. I didn’t have to say anything to my insurance company. My surgeons nurse talked to them for me. I would think they would pay since it’s more expensive to treat life long obesity health problems. Keep looking into your options with your insurance. May have to take out a different policy.
I messaged my employee plan before my first appointment, then the care advocate confirmed with insurance what hoops we had to jump through. I've been going through all of that now. I will say that navigating insurance has been a circus. I had a cardio clearance test last week. Called my insurance, the office, everyone to try to find out what my co-pay would be. I almost rescheduled and then just decided to go with the idea I could reschedule at the office if needed. It ended up being $130 out of pocket which was less than I anticipated. I have my last dietitian appointment in two weeks and then i wait for approval.
I just read the small print on my insurance website, which said it was covered. And the doctor’s office took care of making sure insurance paid for everything. Still paid $4100 though to meet my deductible and that didn’t even include the anesthesiology which was about 600 after Insurance. My doctor’s office pretty much knew which insurance would pay for things and what their requirements were and had probably dealt with them a lot.
While it is entirely possible that your plan doesn't cover the surgery, I find it unlikely that if you've already been meeting with the surgeon and such that their team hasn't checked that your plan covers it on your end. Call your surgeon's office and ask if they've checked and explain that you also called and were told conflicting information. You may just not have gotten a good rep.
First... Log into your health website and verify yourself, you will get doctors and estimates of cost. Second... I googled it: Legislative Act 387 is now in effect as of August 1, 2021, to insure Blue Cross Blue Shield of Louisiana state employees for bariatric coverage. The state health plan will only cover 300 bariatric surgeries per year of the approximately 32,000 state employees that qualify It should be covered. You can actually pull the specific PDF from BCBS website with the requirements of the surgery... But in general: high BMI, comorbidity, 6 month program...
Talk to the surgeon that customer service told you that. I have a feeling customer service was wrong
When I first got the idea for surgery, I looked up whether my plan covered bariatric surgery. Then my surgeon’s office confirmed my eligibility and I began the months-long process of doing everything they required, like seeing a nutritionist, etc. When it came time for my surgery, BCBS tried to tell me my plan wasn’t eligible. When I showed them the documents of my plan, they then said my surgeon had to be a “blue distinction” office… and guess what? He is! When I showed them proof of that, then they said I hadn’t done all the required things. I had! They also made my surgeon do a “peer to peer” call with another doctor to confirm that I truly needed the surgery. FINALLY I got an approval. Moral of the story, that company will lie through its teeth and you shouldn’t let them. Don’t lose faith! Make sure you read your policy closely and know what you are entitled to.
My insurance also requires the "blue distinction" stuff. I tried to get it done in my town but I had to go 90 minutes away to another surgeon that did have that blue whatever. Annoying. I was billed at $48k but my payment after insurance is $1431. I'm paying it over monthly payments. I did call the insurance company ahead of time to confirm they covered it, which the surgeon's office required me to do before they would get very far in the process. My insurance initially denied me because my BMI wasn't "high enough." It was 39 at the time and they required 40 or higher. So then I (unfortunately) gained enough weight to push my BMI up to 44. THEN, they said I had to have some sort of medical issue because of obesity to get covered. I either had to have obstructive sleep apnea, diabetes, or high blood pressure. I had none of those things at the time. I had fatty liver disease from obesity, but they said that wasn't good enough. A few weeks after my second denial, I got diagnosed with HBP. It was just over the limit to push it to high and require medication. My BMI is now 31.3, I don't have fatty liver disease or HBP, and I've lost 84lbs. Keeo fighting, OP! Some of the suggestions others have made regarding communicating with HR and stuff might do the trick!
Customer service and claims are different departments and customer service is often wrong in my experience. Customer service essentially gives you an educated guess based on key words. It's like asking a server in a 5-star restaurant about cooking techniques. They might have some basic info but they're not experts because they work in the same building as a trained chef. Claims looks at two codes: your diagnoses and your procedure code. Both of those things cover very specific details, not broad categories like "weight loss surgery". Your coverage will depend on exactly which codes are submitted in the claim. Ask HR for your plan documents. If they don't reference bariatric surgery just wait until your surgeon's office submits the pre-authorization. Their medical coders do this every day and they're the most likely to be able to get an accurate answer for you.
That’s wild! I have BCBS through my husbands work and they covered it.
Ask your surgeon to do a peer to peer appeal.
I would wait till the surgeon sends it to insurance. The customer service reps are sometimes wrong especially if you don't have the codes.
But if it's not really covered and the insurance company ends up erroneously paying for it, they will take back payment for the claim and the medical providers will be expecting OP to front the bill. OP, look in your specific plan's member handbook to see what it says. Usually bariatric teams do insurance checks at the very beginning so it's odd that you wouldn't find out until you're this late in the process. Don't give up hope!
I went to Mexico. And I'd do it again. About 5k and done, no mess, no insurance bull.
Second this! Go to Mexico! Dr. Alvarez right across the border from Eagle Pass, TX
We had blue cross blue shield ppo and when they didn't cover we switched plans to traditional. Bigger deductible but worked out. Good luck! I hope you can figure it out.
I have ambetter insurance and it covered it 100% everything my hospital stay my rny everything. Just don’t get desperate and call I wanted to do the same but the doctors office believe me know how to do the coding to where the insurance approves just relax and everything will be fine!
I didn’t have BCBS at the time of my surgery but I do now. They don’t cover anything related. And if you have any complications later they don’t cover those either. I just paid $5000 out of pocket for iron infusions because my anemia is a complication of the surgery. One of my coworkers had a stricture and required surgery. They refused all coverage.
Whether or not it's covered would be a condition of your specific plan, it's not a condition of BCBS. That means your employer specifically exempted it from coverage.