Pre-op insurance coverage is still unknow

Nov 12, 2013

When I first started thinking about WLS, I called BC/BS and asked if my policy covered the procedure.  The answer was yes, and all that was required was a letter of medical necessity.

Before my first round of pre-op exams and consultations, I received Mayo's packet of information.  They had specific questions for me to ask my insurance company re:  accepted codes, pre-op nutritional and psychological consultations, whether my plan had any exclusions, etc.  According to the woman I spoke with, all was covered with no restrictions.

My bill for my first pre-op visit at Mayo arrived and all the claims were denied.  I have spent HOURS on the phone with BC and the best they could come up with was that the claims were denied because the code that was listed first (for morbid obesity) wasn't covered.  Now if the code was even 2nd in the list of codes, it would have been fine (so they say).  I pointed out that I had done my due diligence and called and asked all the right questions.  I acted on the information given to me by one of their representatives.  I also pointed out that the code for morbid obesity is required for the letter of medical necessity to have the surgery.  If they cover the surgery, and an in-network physician in an in-network facility tells me there is a series of exams, consults and evaluations that are medically necessary and that  I MUST complete in order to  have the surgery, why on earth would they not be covered?

Mayo was much nicer and more helpful.  For starters they have put my account on hold until January, so I don't have to cough up the cash until the issue is resolved with the BC.  The billing person said if BC said the problem was the code that was listed first, he would send the claims back to the coding department to re-code them.  The re-coding has been completed and the claims will be submitted to BC again in a week or so.  If BC denies them again, my first stop with be with a supervisor in the claims department at BC.  If that fails, I fill an official appeal and lay out that I was told by them versus reality.  I shall not go down quietly, and I shall not quit.  There are apparently several levels of appeal after the initial appeal, and I will bury them in paper.

Regardless of BC being so difficult with the required pre-op workups, I am excited  for my final round of appoints pre-surgery, Tuesday 11/19.  The only other pre-op requirement is a day long nutritional workshop to which I have to drag my husband .  (He's fine with me doing my own thing with food.)

I'm in full fight mode with BC/BS - and I will fight to the end. 

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