Need advice on the process!

[songbird177]

I am so frustrated with my insurance and doctors it's not even funny. I am at the point where I don't know what to do anymore.

I have medi-cal/anthem for my insurance. I am trying to get a DS because it is the best one for me (I need my nsaids, it has the highest weight loss maintained, type 2 diabetic, high bp, high chol/tryglyc, physical disabilities from weight) and I keep hitting dead ends. I know for a fact the anthem part of my insurance covers it, it just needs to be medically neccessary, etc. which I assume it is with a bmi of 47 and the diabetes.

Anywho, been with this pcp since may and I don't like them but ive stuck with them because every other dr ive been to has said no or only believes in the band if i lose 40 or so lbs. I don't want the band, I want the DS! (no offense to those thats had it, its just not for me) And I finally get a surgeon in november, not sure why the office liked to take their sweet time but they did. And he doesn't do the DS and he doesnt like to do it if the patient cant walk a whole bunch. I ride a bike due to the physical disabilities for exercise but i guess thats not good enough for him. Anywho, I find 1 dr in california that does the ds and takes medi-cal. only 1 in the entire state! I give the name, fax, and phone number to the dr and they tell me it's submitted.

So I call anthem. A nice guy said he'd help me and told me what i'd need to do and that he'd call back. Well he never called back so the next day I called anthem and got another stranger, who seemed to be having a bad day. I could tell he got frustrated with me but oh well. I was a woman with a purpose and got to the point. He gave me some bologne speech about to call and follow up with the pcp. I tried to argue and state my case but to no avail. He said my dr submitted the referral with...and get this...The friggin first/old surgeon's name!!! omg! Is this really happening? I am so angry, and I admit it could be the pms talking. I do believe you can only submit referrals for something so many times, anyone know for sure?

I have an appointment on thurs to ask , yet another 'new' dr at this practice, for a referral/second opinion. The last time I tried this it did not go well. The lady said I needed to lose more weight first and something about a band. I am not even sure what to ask for at this point. I know you can self pay a consultation and then have the surgeon write why you need the DS to the insurance but is there anything else I can do at this point to get the consultation? I don't want to self pay and go all this distance if they really can't/won't pay for it. Also, I am supposed to leave on the 6th to go down to this dr (8+ hr drive) for a seminar. Should I postpone this until I figure out things with my pcp? I believe they do them once a month. Or should I just self pay a consult and try to get a new pcp? Thing is, I can get a new pcp but if they don't like wls or won't refer me, I have to wait a whole month to get a new one because anthem only lets you change at the beginning of the month. Plus with a new dr it might be harder to get it approved since they aren't familiar with me.

I am so confused and frustrated! not sure where to go from here..any advice appreciated

[Sandra C.]

You sound like you are on the right track, don't give up trying for the D.S. Its worth it!! Is the seminar thats 8 hrs away a D.S. surgeon? They can help you figure what to do to get approved, and how to handle the other issues you have with your pcp search. I found my D.S. surgeon first, went to his information lecture, talked to his nurse coordinator at the meeting, and e-mailed her after with endless questions how to go about things. They have the experience to help you make it work, and can give you lots of ideas to succeed with the surgery you want. Don't give up, or let long distances to the surgeon make you change from your D.S. decision. you can make it work. I never regretted choosing the out of town surgeon, or the D.S. I love it. Best wishes with your journey!!
;-) Sandra

[Deleted]

If you request a referral and don't receive one, it is a constructive denial. You are entitled to file an appeal of that denial.

[songbird177]

Well it wasn't a denial per se, the drs office sent it to the wrong place even though I supplied them with information of another doctor.

The place I found is Dr. Crookes at USC. He seems to be the only dr in california that accepts medi-cal. I've contacted their office to see if they accept my insurance and they don't think it will be a problem.

Before when I mentioned to my doctor about surgery, I never mentioned specifically which one. I am seeing a new doctor in the same office on thursday and had the idea of telling them I have been trying to get a ds, could they make a second opinion since this other surgeon doesn't perform it. I was told it will keep going back to that first surgeon (the one who doesn't do the ds) as they are the only one in the medical group (not sure if anyone is familiar with anthem) but that I can request a second opinion. I am thinking I should have them put down DS instead of a general bariatric surgery for the referral?

I just don't know if I should go ahead with this seminar (8 hrs away)next week or wait and see what happens with the pcp(s).

[2011Mommy]

Have you considered doing a self pay consult the day after the seminar since you are coming all the way to LA? Maybe they can submit the paperwork for you? I'm not sure how your insurance works but I think you should at least try to meet with Dr. Crookes and see how they can help. Good luck!

[songbird177]

You know, that doesn't sound like a bad idea. If I meet with him I could possibly get a letter from him to my insurance. I am not sure how that works though to get it covered after the self pay. My insurance requires a pre auth to see a specialist and so on. So if I self pay, how would I get them to cover the actual surgery?

[2011Mommy]

I'm not sure how that would work since I have Blue Cross PPO (which means I can go anywhere without a referral). I had HMO and switched over for this very reason... Perhaps his office staff might be able to direct you.

[songbird177]

Well Dr. Crookes office directions were to get a referral to my pcp and attend a seminar and that they can't make appointments until you've attended the seminar. I think I will go ahead and attend the seminar next week, rather than to wait a whole month or so, even though things are kind of up in the air with my pcp doing the referral. That way I can get the easy part out of the way first lol. I just have to show up for the seminar. I have an appointment with a new dr in the same office on thurs, the day before I leave for the seminar. If they deny, I will simply just get another pcp and go from there.

Anyone happen to be familiar with how anthem works? On mine I am part of a medical group. They only have 1 'specialist' and he doesn't do the DS. Will doing a second opinion specifically for the DS work?

Also, has anyone had an insurance where you are required to get a prior auth for a consult but you self paid the consult and then submitted for the surgery?

[lovy19]

Dec 30, 2011 23:03:25 GMT -5 songbird177 said:

Well Dr. Crookes office directions were to get a referral to my pcp and attend a seminar and that they can't make appointments until you've attended the seminar. I think I will go ahead and attend the seminar next week, rather than to wait a whole month or so, even though things are kind of up in the air with my pcp doing the referral. That way I can get the easy part out of the way first lol. I just have to show up for the seminar. I have an appointment with a new dr in the same office on thurs, the day before I leave for the seminar. If they deny, I will simply just get another pcp and go from there.

Anyone happen to be familiar with how anthem works? On mine I am part of a medical group. They only have 1 'specialist' and he doesn't do the DS. Will doing a second opinion specifically for the DS work?

Also, has anyone had an insurance where you are required to get a prior auth for a consult but you self paid the consult and then submitted for the surgery?

hello songbird, I had a similar situation, my story is I had amerigroup which is a HMO and at the time I was seeking consultation with Dr.Roslin for revision from Lapband to DS Yet he did not take that insurance, so what I had to do was change my HMO to HIp Medicaid ( which requires prior referral for consult) but it wouldn't be changed for a month, so what i did was made sure my PCP accepted hip Medicaid and that he had no problem giving me the referral to see Dr. Roslin, I also got Dr. Roslin Hip ID# so that could be prepared when the next month rolled around. To keep busy I went to Dr Roslin's required seminar so that I would be ahead of the game and when the next month came I didn't wait for my card to come in the mail I contacted the insurance company and they read my ID info to me over the phone, I then contacted my PCP and requested the referral, it took approximately two days for Dr. Roslin office to get it, Dr. Roslin office then made the necessary appointments that I needed, they set it up where I did all testing the same day. I did it that way instead of self pay because I didn't want the insurance company feeling that I could pay for the surgery because I paid for consult (maybe that's just my paranoia). I know we have different insurance carriers but maybe this can give you some insight.

[songbird177]

Good point. I'll try to get it covered if I can. I worry about them not covering it if I pay for the consult as well