How I Got Blue Cross to Pay...AFTER the Surgery!

[grumpynonna]

[Apologies: this is a loooong post, but I left in lots of detail in hopes it might be useful.]

Kathleen recently asked me to share with someone who is pre-op what my experience had been with Blue Cross. I decided to pass the information on to all of you, in the hopes that it could be useful to someone who is going through Insurance Hell.

I had Lap Band surgery November 13, 2007. I was self-pay, but Blue Cross unexpectedly ended up paying AFTER the surgery.

Early in 2007, I started researching the whole bariatric surgery process, including insurance. I live in California [Mt. Shasta] and work for Siskiyou County; our insurance is Blue Cross of California. Our policy DOES cover bariatric surgery, if certain criteria are met: basically, you have to be overweight enough, have tried everything else etc. Nothing too unusual in those requirements. However, they DO require that the surgery be done at a "Center of Expertise" IN CALIFORNIA. This is where the sticky part started happening.

At the time [early 2007] the closest COE to me in California was in Sacramento/San Francisco and beyond. With Lap Band surgery, I knew I would need to make multiple trips during the first year for adjustments, not terribly practical in the snow, nor since I work full time. 500 miles round trip was going to add up to a lot of gas, not to mention motel bills, and I'd have to take frequent time off work. I also wouldn’t be able to attend support groups regularly at the same place I had the surgery.

Then I found out that the hospital in Redding [about 65 miles from my home] was "planning to start doing Lap Bands, the doctors are being trained". So I did the intake process with them, went through all their hoops, and assumed that Blue Cross was going to pay, though we hadn't actually gotten to the insurance authorization part yet, which they wouldn't do until just before the surgery [!?!?]

Waiting for them to begin to do Lap Bands went on and on. I was attending their support groups, and I really started not liking the manner in which they were dealing with potential Lap Band patients: no separate info, no separate support, difficult to get specific questions about the surgery and post-op process answered ["we'll tell you when you need to know"].

At some point in about August 07, I got really frustrated and decided to check again into RVMC. I had called earlier in the year, and whoever I talked to then was pretty sure Blue Cross wouldn't pay for surgery outside of Calif, so I didn't continue to pursue surgery at RVMC at that time.

This time, whoever I talked with was pretty sure she knew that someone HAD been paid for by BC Calif. So with this shred of hope, I investigated RVMC/SOBC and really really really liked what I was seeing of them. My daughter and I went to the seminar and were convinced. We much preferred their program and people to what we had experienced in Redding.

So I began the intake process, and at some point Kathleen suggested I call Blue Cross to be sure they really would pay. OK, here's where we finally get to "what I did":

1---Phone call to Blue Cross "coverage" dept: the person on the phone checked all the info, put me on hold to talk with his supervisor, and came back with “YES, we will cover this out of state,” per their “out of state’”clauses about surgery in general, even though it specifies a Center of Expertise in California for bariatric surgery.

2---Phone call to Blue Cross again [not sure why I called again]: new person did the same, talked to her supervisor, and came back with : “NO, absolutely not, it MUST be a COE in CALIFORNIA.” [Their files on me didn't have the specific information that I had been "ok'd" by the first guy, only that I had called before....how convenient for them!] NOTE: I SUGGEST THAT WHENEVER YOU TALK WITH SOMEONE BY PHONE THAT YOU REQUEST THAT ALL INFORMATION BE SPECIFIED IN THEIR PHONE LOG IN YOUR FILE, NOT JUST THAT YOU CALLED.

3---Made another phone call hoping for a tie breaker: told person #3 all the above, she basically said she wasn't going to get into the middle of it, and told me I needed to call the AUTHORIZATION department

4---Authorization department said “NO WAY, must be a California Center of Expertise.” I asked to talk to a supervisor, got the same answer. I tried to explain what the surgery and all the follow ups would entail, and also pleaded with them to please LOOK AT A MAP so that they could get some perspective on Mt Shasta here, San Francisco there, and Medford right over here. Sorry, no, must be in California....yes, you can have any other surgery in Medford, just not this one. How logical [and discriminatory?!]

5---In the above call, I asked how to appeal this answer. I was given the phone/fax number of where to send a letter. I composed a letter with all details of why it would be nuts to do the surgery 250 miles from my home, as opposed to 85 miles. The response was a FORM LETTER, devoid of any acknowledgment of the reality of the situation, which said: here's the rules: no bariatric surgery out of state [basically, “because we said so.”]

6---Somewhere in here I reached my limit with trying to have a sane conversation with Blue Cross. In my usual stubborn way, I said screw Blue Cross, I want the surgery, I have done tons of research and know this is what I need to do to have any quality of life, I have been accepted by two medical centers as physically and emotionally acceptable, I'm 61 [at the time] and not getting any younger, only fatter. Therefore, time to refinance the house and pay for this myself.

7---So even though it had not been in my plans, I went ahead and refinanced.
[I need to interject at this point that EVERYTHING I needed to do to have my surgery at Rogue Valley went off like clockwork...the refinancing was smooth and without hassle, the pre-op stuff just moved right along...the whole process from seminar to surgery was about 2 months....as opposed to the 7-months-and-still-waiting-at-that-point with Redding. I did have to do a little chatting with myself about "am I nuts to pay for this myself?", when if I "just knuckled under” and followed Blue Cross rules and either went to San Francisco, or waited for Redding to start doing Lap Bands, Blue Cross would pay. But somehow, the self-pay and RVMC felt absolutely right. It also helped me to recognize that the cost of the surgery was an amount that I wouldn't blink at if it were a new car..and a not very pricey car at that!]

8---During the pre-op process at RVMC, I did ask at least three different people [don't really remember who] to please bill Blue Cross anyway, even though I was self-pay. For whatever reason, it never got done, nor did a formal request for pre-authorization get done. No one's fault, probably just that I was in the self-pay mode and that was that.

9---A month or so after the surgery, I called the RVMC billing office, and asked for an itemized bill, so that I could have one for my records, tax purposes etc. On a total whim, I asked if they could please bill Blue Cross, just to see what happened. I really didn't have an emotional investment in it at that point, I'd already had the surgery, so if they said no, so what?

10---The next thing I knew I got a letter from Blue Cross saying they were looking into the bill and were requesting more info from the surgeon etc.

11---The request for info from the surgeon was answered by a letter from Kathleen, which basically stated the reasons I had needed the surgery and that I was doing well etc etc etc

12---Not long after that, I got the standard form [can't remember what it's called] which says what they paid and what my share was. I was pretty flabbergasted....and to this day, I truly don't know WHY they paid [and I have avoided calling to ask them why they changed their minds!]
I DID call them to clarify if the $12,000 and change that they paid was just for the hospital, or was it for surgeon, anesthesia etc. The person I talked with was sure it was just the hospital and not surgeons et al. But since I didn't trust much what the front line people at Blue Cross might tell me, who knew what it was really for.

13---Because they paid a percentage and not the whole amount, I called RVMC billing department to discuss with them how they would do the calculating, since I had paid for surgeons etc in that total fee, and Blue Cross hadn't [apparently] taken their charges into account [or had they?]. My file ended up being handled by Jennifer Johnson, the head of the department. She did all the figuring, including figuring out how to divvy up what Blue Cross paid with all the parties involved, who got owed what etc etc etc. I really didn't understand exactly what she did, but I trusted her to make sure everyone got what the amount that was appropriate and to determine what my ultimate co-payment should be.

14---When all was said and done, RVMC refunded to me the entire amount I had paid them. They accepted the insurance payment in full as a preferred provider rate, if I understood correctly.

So that's the "how I got them to pay" story. It was a pretty unusual case, from what I've heard, and as I said, I still am not sure why Blue Cross changed their minds. When I'm philosophical about it, I figure it was because I didn't care anymore and had let go of ever hoping to get them to pay.

On the other hand, perhaps the person who received my bill actually looked at my whole file and read my appeal and used common sense and logic to put together the whole nonsense of the fact that with our policy, a person could have heart surgery in Medford, but not bariatric surgery....just because I live in California!

I hope some of you might find this information useful, even if your circumstances differ. I think my best advice to anyone struggling with their insurance company is : Don’t give up. Be persistent. Ask to talk to a supervisor. When the answer is no, ask what the appeal process is. Even when they say no, DO assume you still have options. Keep records of all your conversations, correspondence, etc. Check with Allergan for legal advice; I think they advocate when necessary. I don’t know details, but from what I remember in my research, insurance companies are slowly coming around to the fact that obesity is a disease, and that they need to not discriminate against obese persons and need to pay for what is a proven treatment.

And yes, I’d do it all again in a heartbeat...the surgery is SO WORTH THE COST!!! Good luck!!!

[marissa]

I'm just wondering how common it is for Blue Cross to pay after the surgery. Am I taking a big risk to get the surgery done and hope my insurance will pay? I'm also wondering if anyone has completed the surgery using private health insurance and if so, what was your experience like? Did you have to go through a lot of red tape to get the surgery approved?

[grumpynonna]

Hi, Marissa....

Well, I can't say as I am an expert of any sort on getting insurance to pay, whether before or after the surgery. Truth be told, I didn't expect my insurance to pay at all, after all the asking/applying/protesting I did of them....as I said in my previous and long post [see #6 and #7], I just gave up, really gave up on them, and refinanced my house, which I was fortunate enough to be in a position to do [also before economy/housing tanked, etc etc....another bit of luck].....at that point I had no reservations whatsoever about paying for the surgery myself [I didn't especially want to have to increase my mortgage payments, but it felt really really worth it to me]...I didn't at that time plan to bill them again after the surgery, none of that...I was finished with Blue Cross. In philosophical terms, I had completely "let go" of the insurance company....don't know how I did that excactly, not having been terribly successful in the past in "letting go" of much else in my life [starting and ending with eating and getting fat!], but basically: I really wanted the surgery and was committed to doing whatever I needed to to get it done.

It was just a whim/fluke that I asked the billing office at RVMC to please bill the insurance...this was a month or so after the surgery, when I had called them to request an itemized bill, just for my records, tax purposes etc. While I was on the phone, I just asked them to bill, with a definite "what the heck, can't hurt" sort of attitude. Wasn't planned pre-surgery. And the fact that they DID pay is still a bit of a mystery to me...they have denied others who also live in California, and who have pretty much the same insurance as I do.

As for how common it might be for insurance to pay after the fact, you should ask Kathleen, she would probably know, or have an idea, or at least who to ask. I personally wouldn't advise anyone to gamble that the insurance might pay after the fact....unless you are comfortable enough to live with the possibility that there's absolutely no guarantee they will pay....I'm not a financial expert, and this is my opinion only. If you're really ready to pay for the surgery yourself, I'd say it would be better if you have given up on any hope of the insurance...then whatever payment they make can be a big [and happy!] surprise...again, this is only my opinion....PLEASE talk with family/financial advisors etc, who know you/your situation better......if you are holding on to the hope that maybe they will pay, it may be [this just came to mind] like hoping, one more time, that maybe, just maybe, THIS diet will work!!!! And we all know how far that has gotten us!

Meanwhile, at this point, 2 years and 5 months after Lap Band surgery, I am delighted with the results, and wish I had done it sooner....I have lost 107 of the 130 lbs I had to lose, and am wearing "regular" clothes again....no "X's" in the sizes anymore.....wheeeeeeeee!

Good luck and keep us posted with what happens!.............Diane

[kathleen]

wow Diane,
thank you for all that great information. i am sure it will be helpful to many.

you are an inspiration!

warmly,
kathleen

[marissa]

Diane,

Thank you so much for the information. You've been a tremendous help!

Thanks again,
Marissa

[kathleen]

Thank you Diane for being so supportive of everyone here!

kathleen