AtomicMelanie
Dread Pirate
@DianaCox and @Larra -
New here. Have BCBS of NC (Blue Options), attempting to have DS w/ Dr. Williams (Boyce) in Knoxville TN. Have verified he's in network. Surgery is not excluded from my policy. I meet all the medical requirements and we submitted all the required documentation. Dr. Williams' office has not had much experience in dealing with BCBSNC for DS patients - it appears that I'm their first.
BCBSNC denies coverage and says Dr. Williams's post-op follow up program doesn't meet their criteria. BCBSNC policy guidelines say "follow-up programs must include regular follow up for at least 5 years, including postoperative nutrition follow-up."
Am currently in Level II appeal, independent grievance panel review is set for Feb. 19th (by telephone).
Dr. Williams's Program Outline shows 1 year of post-op follow up with the patient coming in to his office. After that, he gives the patient the option to follow up with either him or the patient's primary care doc annually (supposedly to save them money from having to continue to pay a specialist co-pay), but either way, annual follow-up is required.
BCBSNC didn't like that. In our first-round "soft" appeal and "courtesy peer review," Dr. Williams and I both submitted letters to state that it was my intention to follow up with Dr. Williams annually for life. We were denied, so we filed Level I formal appeal. Denied again, same reasons as above.
I found out that the office manager for Dr. Boyce/Williams requires a copy of their Program Outline to be included in every insurance appeal filing. So, BCBSNC is seeing conflicting information from the doc and me and the practice's program outline. Of course, BCBSNC is choosing to go with the document that will allow them to deny on a technicality.
We have filed Level II appeal. I demanded to Dr. Williams staff that they do NOT include the Program Outline in this filing. Further, they had me sign, in the presence of a witness, a Patient Contract of Commitment, with the below language added. A copy of the contract was sent to BCBSNC in our Level II appeal package.
Language added to the contract I signed:
"I understand that New Life center for Bariatric Surgery requires patients to follow up with Dr. Williams/Dr. Boyce and staff in person, in office for a minimum of 5 years post-op. This follow up will be in person at New Life Center. Visits to include medical and nutritional care at the following postoperative visits: 2 weeks, one month, two months, 4 months, 7 months, 12 months, and annually thereafter for a minimum of 5 years."
How does it work with the Level II appeal independent review? Do you think this would satisfy them? I will be on the call. How can I advocate for myself to stress to them that Dr. Williams provides lifetime follow up?
Many thanks for your help!
New here. Have BCBS of NC (Blue Options), attempting to have DS w/ Dr. Williams (Boyce) in Knoxville TN. Have verified he's in network. Surgery is not excluded from my policy. I meet all the medical requirements and we submitted all the required documentation. Dr. Williams' office has not had much experience in dealing with BCBSNC for DS patients - it appears that I'm their first.
BCBSNC denies coverage and says Dr. Williams's post-op follow up program doesn't meet their criteria. BCBSNC policy guidelines say "follow-up programs must include regular follow up for at least 5 years, including postoperative nutrition follow-up."
Am currently in Level II appeal, independent grievance panel review is set for Feb. 19th (by telephone).
Dr. Williams's Program Outline shows 1 year of post-op follow up with the patient coming in to his office. After that, he gives the patient the option to follow up with either him or the patient's primary care doc annually (supposedly to save them money from having to continue to pay a specialist co-pay), but either way, annual follow-up is required.
BCBSNC didn't like that. In our first-round "soft" appeal and "courtesy peer review," Dr. Williams and I both submitted letters to state that it was my intention to follow up with Dr. Williams annually for life. We were denied, so we filed Level I formal appeal. Denied again, same reasons as above.
I found out that the office manager for Dr. Boyce/Williams requires a copy of their Program Outline to be included in every insurance appeal filing. So, BCBSNC is seeing conflicting information from the doc and me and the practice's program outline. Of course, BCBSNC is choosing to go with the document that will allow them to deny on a technicality.
We have filed Level II appeal. I demanded to Dr. Williams staff that they do NOT include the Program Outline in this filing. Further, they had me sign, in the presence of a witness, a Patient Contract of Commitment, with the below language added. A copy of the contract was sent to BCBSNC in our Level II appeal package.
Language added to the contract I signed:
"I understand that New Life center for Bariatric Surgery requires patients to follow up with Dr. Williams/Dr. Boyce and staff in person, in office for a minimum of 5 years post-op. This follow up will be in person at New Life Center. Visits to include medical and nutritional care at the following postoperative visits: 2 weeks, one month, two months, 4 months, 7 months, 12 months, and annually thereafter for a minimum of 5 years."
How does it work with the Level II appeal independent review? Do you think this would satisfy them? I will be on the call. How can I advocate for myself to stress to them that Dr. Williams provides lifetime follow up?
Many thanks for your help!
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