Prideth

My experience with BCBS Federal

14 posts in this topic

Looking back, I realize it was very daunting to me to begin the process of bariatric surgery. I had thought about it for years, but I was scared of the process and the prospect.  I felt like my insurance benefits explained the requirements very vaguely and I really wanted a good overview of what to expect.   Even on forums I didn’t get a good grasp; so I would like to help someone who (like me) may be looking for answers and what to expect.   I will share my personal experience with Blue Cross Blue Shield Federal Employee Program (FEP Blue).  I have the Basic option.

To start my journey, I went to the FEP Blue website and downloaded the Service Benefit Plan (http://www.fepblue.org/downloads/2013-service-benefit-plan-brochure_100512.pdf).   Pages 59-60 detailed what was required of me prior to surgery:

  • No smoking for 6 months prior to surgery.
  • No substance abuse or treatment of substance abuse for the last year.
  • 2 years of morbid obesity(BMI over 40).  Any visits to the doctor will count since they always weigh you before every visit.  Even walk-ins!
  • Evidence that attempts at weight loss in the past 1 year have been ineffective.  I was only required to write down the names of diets and pills that I had tried and failed.
  • Psychological clearance.  My surgeon’s office referred me to a psychiatrist that they worked with before.  The psych basically wants to hear that you know what you are getting yourself in to and that surgery wasn’t something you decided to do when you woke up this morning.
  • Participation in a medically supervised weight loss program for at least 3 months prior to surgery.
    • What I found out from insurance:  Weight Watchers, LA Weight Loss, Jenny Craig, etc. are NOT considered medically supervised, even if you are seeing a nutritionist or dietician who is a registered nurse. It MUST be a doctor.
    • The easiest route: I was told I could see my primary care provider once a month for three months, but I had to be seen specifically for weight loss with a record of my progress.  IN ADDITION, I needed to see a nutritionist once a month for the same three months.

 

The last detail you should note is that your insurance will fully cover (mostly) the cost at what they call a “Blue Distinction Center”.  I highly recommend you choose one of these centers, they are picked out because they have the whole team to guide you through your experience.  My surgeon’s office had everyone I needed to see: A nutritionist, an insurance person (who was great at outlining exactly what I needed and collected all of my requirements), nurses, and of course the surgeons.  You can find a blue distinction center through their website, here: http://www.bcbs.com/innovations/bluedistinction/center-list/selector-map.html

 

Did you catch that last bit where I mentioned they will *mostly* cover your expenses?  FEP Blue will not cover your visits with the nutritionist, or with initial visits to the surgeon.  They WILL, however, cover these costs post-op.  Here’s how it went down for me (your experience may vary):

$150 - Initial bariatric consultation with Bariatric Institute and metabolic testing

$175 – Nutritional consultation and body testing

$225 – Surgical Consultation.

$25 – 1 visit with Psychiatrist (copay)

$75 - 3 Primary Care Provider visits (once a month for three months.  $25 copay per visit)

$120 – 3 Nutritionist visits (once a month for three months.  $40 per visit)

$35 – Pre-op visit

$300.00 – Surgeons Fee (I will have two surgeons doing my surgery and it is $150 fee for each)

 

Totalling $1105 before my actual surgery.  After that, I only owe a copay to see my PCP, nutritionist, and Surgeon at regular follow ups.  For me, it has been completely worth it; the surgical team has been fantastic every step of the way.  For reference, I go to the Bariatric Wellness Institute (http://www.lapbariatrics.com/) in Huntsville, Alabama.

 

While your costs might differ from mine (but not by much, I would assume), I think this post might give you a good idea of what to expect.  I really hope this has helped someone, I know I would have loved a rundown of everything before I spent hours on the phone with insurance and trying to figure everything out on my own.

 

My files were submitted for approval on October 8.  I was approved by insurance on October 18th, and I am scheduled for surgery on November 18th.  :)

 

Good luck with your own journey!

 

 

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Thanks for sharing the information, I'm sure someone will benefit from it.

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Prideth,

Thanks so much for the post. I have Blue Cross Blue Shield Federal and I have met all the requirements for my surgery except the below.

(Evidence that attempts at weight loss in the past 1 year have been ineffective). You mentioned that you only was required to write down the names of diets and pills that I had tried and failed.

When you wrote down the names do diets and pills, was it in a letter format?

Would you mind sharing that with me, my doctor plan on submitting my paper to the insurance company on 12/24/2013 and I would like to have that to them by 12/23/13.

I really appreciate your post.

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Prideth

Do you have the standard or basic BCBS Federal policy? My wife was told 5K out of pocket with 15% coinsurance. She has the standard policy.

thanks

Mark

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I have BCBS Highmark and they were pretty good. I had the same qualifications that you mentioned and met them all easily without any questions asked....The only problem I had was with the lack of proper documentation from my Dr, it extended my wait period for 4 months which was very discouraging...... But the good part is that I only had a $10 co-pay for each of my office visits. Nothing for the pre-op, post-op or hospital stay or deductible...I was pretty happy with them!

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Every state is different when it comes to insurance laws, and even if you're in the same state, plans vary considerably. Check your own policies!

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Great post - here is my breakdown~

 

I have Fed BCBS Basic option, my experience/cost was pretty similar with a few exceptions:

 

$150 - Initial bariatric consultation with Bariatric Institute and metabolic testing - This was not required for me

$175 – Nutritional consultation and body testing This was covered for me with a co-pay of $25

$225 – Surgical Consultation. - This was covered for me with a copay of $25

$25 – 1 visit with Psychiatrist (copay) - Same

$75 - 3 Primary Care Provider visits (once a month for three months. $25 copay per visit) Same, and my Bariatric center provided my PCP with a monthly supervised diet form to fill out for submission to insurance. - plus an example of the letter of medical necessity for the insurance submission packet.

$120 – 3 Nutritionist visits (once a month for three months. $40 per visit)- I was not required to do this at all.

$35 – Pre-op visit - There was no fee for this in my case.

$300.00 – Surgeons Fee (I will have two surgeons doing my surgery and it is $150 fee for each) - I had a $25 copay for this

 

$125 per night co-pay for hospital room = $375

 

Total = $550

 

 

So my total was 550, I think some of it depends on what the the specific bariatric program requires as well. I also went with a Blue Distinction Center and highly recommend going that route with BCBS Fed.

Edited by ✿ Aprilwine ✿
amyandjim likes this

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Plus Size,

I guess it's a little late for a reply, but yes, all I had to do was write down the names of the plans/diets/pills I've tried on a form provided by my surgeon. They didn't require a letter or receipts or anything.

Mark,

I have The Basic option of BCBS Fed, but I'm sure the plans are pretty similar (I checked the service benefit plans during open season this year). You might want to go look at that to see what is covered. Obviously, I had some costs that weren't covered by my insurance (nutritionist), but were required by my surgeon, not my insurance. So it's possible the surgeon has other hoops to jump through. Get an insurance person on the phone to iron it out. Hope that helps!

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I just saw this... what was the copay for the anesthesiologist?

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I just saw this... what was the copay for the anesthesiologist?

 

 

I my case, this was fully covered in the surgical fee.

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Prideth

Do you have the standard or basic BCBS Federal policy? My wife was told 5K out of pocket with 15% coinsurance. She has the standard policy.

thanks

Mark

Hi Mark

I have the basic BCBS federal plan. Unfortunately it seems than the standard plan actually has more out of pocket expenses over the basic plan. Not sure why when the insurance is more expensive to begin with. Next open enrollment I recommend sitting down and doing a plan comparison with your wife, standard vs. basic. I can almost guarantee you will come out better with the basic.

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Yikes. I have BCBS Federal standard. It is so much better for us, cost wise, in many ways. Now I'm worried about the cost of surgery. I just have to wait and see. Thanks for posting this. It helps.

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Yikes. I have BCBS Federal standard. It is so much better for us, cost wise, in many ways. Now I'm worried about the cost of surgery. I just have to wait and see. Thanks for posting this. It helps.

Im not sure about standard. Basic has copays where standard you have to pay the coinsurance. I would rather pay a set copay any day because a coinsurance (10-20%) of any charge seems to always be higher than my $20 copay for random services...

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On 2/2/2014 at 7:26 AM, ✯AprilWine✯ said:

April thanks!

I also have Basic.  My hubby and I both need it but he has to lost at lease 70lbs before they will operate on his back so he can hopefully work again. So he gets it first. I went to a free seminar this past week and was told most of what you had. My biggest question is why you didn't have to pay the Initial Consult fee($175 for each of us. You'd think we could get a discount) ? If we didn't both have to pay this, we could both do the surgery at the same time. We think that would make it a lot easier. No bad food in the house because one person is still eating, etc.  When I asked at the seminar why thy didn't bill it as a level 5 office visit, they said BCBS won't pay for it because it is a consult and not an exam. Of course I'll still try to file it on my own. Just wondering....

Huntsville hosp is one of the BCBS Distinction facilities so that helps with our cost too.  We have lots of proof that over the last 2-3 years we have both tried to lose weight through the Dr's with pills or shots. But they are saying that it has to be 3 months in a row. Did you find that to be the case? I don't know if either of us have it 3 months in a row. 

Thanks for the post

On 2/2/2014 at 7:26 AM, ✯AprilWine✯ said:

 

 

Great post - here is my breakdown~

 

I have Fed BCBS Basic option, my experience/cost was pretty similar with a few exceptions:

 

$150 - Initial bariatric consultation with Bariatric Institute and metabolic testing - This was not required for me

$175 – Nutritional consultation and body testing This was covered for me with a co-pay of $25

$225 – Surgical Consultation. - This was covered for me with a copay of $25

$25 – 1 visit with Psychiatrist (copay) - Same

$75 - 3 Primary Care Provider visits (once a month for three months. $25 copay per visit) Same, and my Bariatric center provided my PCP with a monthly supervised diet form to fill out for submission to insurance. - plus an example of the letter of medical necessity for the insurance submission packet.

$120 – 3 Nutritionist visits (once a month for three months. $40 per visit)- I was not required to do this at all.

$35 – Pre-op visit - There was no fee for this in my case.

$300.00 – Surgeons Fee (I will have two surgeons doing my surgery and it is $150 fee for each) - I had a $25 copay for this

 

$125 per night co-pay for hospital room = $375

 

Total = $550

 

 

So my total was 550, I think some of it depends on what the the specific bariatric program requires as well. I also went with a Blue Distinction Center and highly recommend going that route with BCBS Fed.

 

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