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ashchkat | Can I be denied coverage for lap band if I have BC/BS PPO and the doctor is an out-of-network provider? |
My mom currently has BC/BS PPO federal employee insurance and I am covered under her health insurance. I am 19 years old and morbidly obese. I recently went to a doctor and they took a copy of my insurance card and said that I have 75% coverage for an out of network doctor. Now after all the paperwork has been submitted my insurance says they will only cover $1,000 worth of the total procedure. The total procedure is a total of $20,000. How does this make sense? Does it make sense to deny me even if I have PPO? What should I do? Please help. |
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sarah314
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They aren't denying you - they told you they would pay $1,000. That's not a denial.
Your 75% coverage does not mean that BCBS would have to pay 75% of whatever the doctor decides to charge. It means that BCBS would have to pay 75% of the out of network fee schedule rate. (Which, apparently, works out to $1,000.)
If the service were being denied, BCBS would not pay anything at all towards the service.
What should you do? Either pay the difference out of pocket yourself, or find a network doctor to perform the procedure for you. (If you switch doctors, you'll want to make sure that your prior approval for the procedure is transferred to the new doctor.) |
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acermill
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Ehhhh.....mbrcatz is totally correct. If your obesity is caused by your overeating or eating the wrong foods, combined with lack of exercise, that's what you need to control instead of reaching out for lap band or gastric bypass. Those procedures merely make it simpler for you to control your food intakes. Aside from that, those procedures have unpleasant side effects and some of those are worse than dieting on your own.
The reason that insurers don't pay for gastric bypass or lapband is that there ARE other ways to lose weight, by yourself. If you are NOT overeating, then perhaps your weight problem has a different medical cause. Get a complete physical check up to rule out any other metabolic disorders. If there are none found, start dieting and exercising. |
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tamiam
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you need to find an in network provider that will do the surgery. You will probably have to start the approval process all over, but if the insurance covers it, you won't have nearly the out of pocket expense. Unless your policy has a $1000 maximum for that type of surgery, which is quite possible. |
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mbrcatz
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Well, it makes sense because basically most plans consider lap band surgery to be a VOLUNTARY procedure, like cosmetic surgery.
You can't demand someone pay for your nose job, your boob job, or your lap band.
You seriously need to look at alternative methods. Lap band is NOT a permanent solution - five years after the procedure, 85% of the patients are at their pre-surgery weight, or higher. It has a high mortality risk - the procedure, I mean. And if you don't make the basic lifestyle change of food choices and excercises, it's not going to do any good.
That's why insurance companies want you to pay the majority of it - because if YOU don't invest the time and effort to make the change, it's not going to work.
In the long run, YOU have to take responsibility for your own health. And obesity IS something within your control.
Hey, I know, I'm kissing away the best answer points with this, but hey. It's YOUR life. YOU DO have the power to change this. It's not fair to ask someone else to do a temporary change, when YOU don't want to put the effort into doing the change. |
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tngandhkm
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Read the policy you have, it will specify what procedures are covered and what isn't covered. Depending on your policy option BCBS may elect to cover the procedure if you meet their criteria of having a BMI of 40 or more or a BMI over 35 with co-morbidities (high blood pressure, sleep apnea, things like that) AND other weight loss treatments have failed. Insurances use that last one liberally with weight loss surgery. They may want to see an extended physician supervised weight loss program for 6 months. You can also go to the website obesityhelp.com for additional information and help in fighting insurance denials for weight loss surgery. |
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