|
|
Post by songbird177 on Jan 11, 2012 23:21:02 GMT -5
My pcp's office seems to be giving me the run around and I can't find out what I need to do so asking the experts here.
Basically i need to go outside of the medical group (network?) to get a DS. How can I do this? My drs office seems to think that if they keep resubmitting the same referral it will get us somewhere. There is no one in the medical group that does the DS. Is a second opinion the best option? Or would they just not send me to a DS surgeon still?
|
|
|
|
Post by keliblue on Jan 12, 2012 13:19:55 GMT -5
I'm sure there's vets that can answer this more clearly.. I'm from California and had to file an appeal to go outside my network (not anthem) If you go to dsfacts.com there is a step by step on how to do this. If you've already been approved for WLS your halfway there..
good luck
kb
|
|
|
|
Post by songbird177 on Jan 12, 2012 17:39:59 GMT -5
They are not denying me, just sending my to a bariatric surgeon that doesn't perform the DS
|
|
|
|
Post by bldeck on Jan 12, 2012 17:48:54 GMT -5
Have you spoke to your insurance. I have BCBS-FEP, they have a customer care specialist you can speak with that will help you with insurance. I don't know if this is true for your insurance but I Would call my insurance to see what they require before I relied on my doctor doing it. You insurance will have more information on what they want then your doctors office.
Betty
|
|
|
|
Post by songbird177 on Jan 12, 2012 18:14:16 GMT -5
I've called and talked to the insurance. They said you had to go to the doctors in the medical group unless there was no specialist and in that case your pcp can do something called an access to care. I couldn't find any info on this online. Anyone know what it is? So I told my doctors office to do that for me and they said they can't that the medical group has to do it. I thought they were doing it for me but I guess they just resubmitted another referral. I don't know what to do! If they keep resubmitting for a referral they will just send me to the surgeon who doesn't perform the DS! My dr's office is really stressing me out and I don't know where to go from here  |
|
Deleted
Deleted Member
Posts: 0
|
Post by Deleted on Jan 12, 2012 18:32:21 GMT -5
I was on my third appeal for a similar reason...they told me I could not go out of state...so I called every Center of Excellence listed...was on my final one here in town when I got the news that the two surgeons in the practice were willing to let me change from one to the other.
While I was calling, I got names of who I spoke to in the office, their position and whether or not the surgeon/s listed did a DS AND in my case, would do one on a lightweight.
Like I said, I had run out of options except for Dr. Boyce. Either the ones listed as doing a DS did not accept Medicare policies (had BCBSTN Medicare), or did not operate on lightweights. And a couple of them were completely out of network.
I was fighting to go to one I had found in NYC.
Anyway, I got lucky in that Dr. Boyce aggreed to take me as a patient, aggreed to do a DS and on a lightweight.
But it takes finding out what they are looking for in the appeal process. I got lucky in that one of the nurses told me I had to detail all the surgeons in the state and put down all the info I found...not in network, only DS on 50+ BMI, etc.
Having nationwide phone access does help with this as you are calling all over the state.
Good luck and I hope you find someone.
Liz
|
|
|
|
Post by songbird177 on Jan 12, 2012 22:48:20 GMT -5
Thank you for sharing. It helps me not feel like giving up, that there is still hope out there to get this covered somehow
|
|
|
|
Post by keliblue on Jan 12, 2012 23:12:34 GMT -5
They are not denying me, just sending my to a bariatric surgeon that doesn't perform the DS You've been approved for the RNY which you don't want.. I was to... now you have to file an appeal to get the surgery you want out of network.. that's what I had to do.. be glad your in California, it takes time but we have two of THE BEST DS surgeons there are and we have the "California Dept of Managed Health Care".. now read this and do exactly what it says.. it was written by our very own Diana. It worked like a charm for me.. just bring your patients ( dsfacts.com) What you are trying to do FIRST is to get yourself approved for WLS in general (likely the RNY), so that when you start to fight for the DS, you are only fighting for WHICH surgery you should have, not whether you qualify in the first place. If you start out asking for the DS with a company that has an exclusion of the DS in their policy, they will make your life miserable at every turn to try and keep you from getting approved for WLS in the first place -- they will get hypertechnical with the 6 month diet requirements, with the proofs of being MO for 5 years, etc. They are generally less picky with the RNY.
Note that in CA, you can avoid the 6 month diet or 10% weight loss requirement by immediately appealing to the CA Dept. of Managed Health Care. But if you don't fast track that appeal, it will take 4-6 months anyway. I can help you get in contact with the right people at the DMHC if you come across one of these requirements.
While you are in the approval process for WLS, find yourself a DS surgeon. Get a consult, and pay out of pocket for it. Get a letter written for you by the DS surgeon that explains why the DS is better for YOU than the RNY. This can be because you are SMO, have a family history of stomach cancer, have arthritis or other reasons to need or expect to need in the future to take NSAIDs, have the need to be on anticoagulants, have a Nissan wrap, or some other PERSONALIZED reason. You may as well get the psych consult out of the way at the same time.
In the meantime, you will be writing your request for the DS for after you are approved for the RNY. You are gathering the papers that show the SUPERIORITY of the DS to attach to your request.
When you get approved for the RNY, you IMMEDIATELY submit your request for the DS instead, including the well-written letter with your reasons why you want the DS, copies of the scientific literature supporting your reasons, and the letter from the DS surgeon recommending it for you in particular.
The insurance company will take every day of the permitted period to deny you. You will try not to take this personally (HAH!).
You will take their denial, and IMMEDIATELY submit a request for a second level review. It will essentially be a copy of the first well written letter, with a request for reconsideration. You will maintain your calm, because there is NOTHING personal about this -- it is business (note that I was completely unable to follow this rule and wasted a lot of unnecessary emotion on this part of the process).
The insurance company will take every day of the permitted period to deny you again.
What happens next depends on your type of insurance, and possibly which state you live in. If your plan is self-funded, the company ultimately has the power to overrule the insurance company, and your route of appeal is through the company's HR dept. If your insurance is fully funded, then you likely have the right to external medical review -- that information should be provided to you in your second level denial.
In CA, that review is generally to the CA Dept. of Managed Health Care, which is VERY pro-DS. The process takes about 30-60 days (I believe it's 30 days from when the DMHC gets a copy of your medical records and appeals from your insurance company), and at the end, they overturn the denial in most cases. The process may vary in other cases, but the important thing is that EXTERNAL medical people will review the case. |
|
|
|
Post by songbird177 on Jan 13, 2012 2:44:39 GMT -5
I wasn't approved for any surgery though, just saw the surgeon at a consult and he said I wasn't a good candidate for surgery which was ok because I want a DS, not what he offered.
|
|
|
|
Post by keliblue on Jan 13, 2012 12:50:10 GMT -5
I wasn't approved for any surgery though, just saw the surgeon at a consult and he said I wasn't a good candidate for surgery which was ok because I want a DS, not what he offered. OMG !! did you NOT read what I posted  you HAVE to get approved for the RNY first THEN start the process to get the DS.. most insurance co. will not approve the DS when they can stick you with the RNY.. I guess I should ask you.. why did the surgeon tell you that you were not a good canidate for the RNY ?? i |
|
you HAVE to get approved for the RNY first THEN start the process to get the DS.. most insurance co. will not approve the DS when they can stick you with the RNY.. 