Insurance, HMOs and appeals Questions

Here is my latest delima....I have Pacificare HMO with my current managed care program that offers WLS, however after meeting with the actually surgeon yesterday (met the first that was nice but this one is the head of the program and I didn't like him) I don't want him to touch me PERIOD approved or not! Ok I want to know what has been your experience with going to a different Surgical group that is in the network but outside your manage care...example I have UCSD managed care group but I would like to go across town to Scripps Mercy for just this surgery because I like my pcp. Will I have to change everything from PCP, etc? OH and if I was denied VSG from one group how likely do you think the new surgeon that has better VSG approvals work? I mean I was down for RNY but this freaking man flat out told me "I don't do that type of surgery on people like you." I know don't ask...please advise and I did post this on the insurance forum oh yes please give some doctors that have been successful with VSG approval from insurance here in San Diego or near it!

That is ridiculous, I wouldn't want that doctor either. Have you thought about the Sharp Medical Group? I LOVE THEM! they are the best and I cant rant and rave enough about Dr Mueller.

I wouldn't go with any surgeon unless I felt comfortable with them. As far as changing your PCP I really don't know.

Good Luck

Kellie

I can't answer your questions, but I will recommend that you read your policy for yourself to determine both what operations are covered and what their policy is for going to a surgeon who is in network but outside your managed care. There are so many different policies available these days that you really have to look carefully at the specifics.
    If what is "covered" isnt' what you want, you do have appeal rights. Whether your appeals will be successful depends on both your policy and on what you are requesting. If your insurer won't go for the VSG, I'm not sure you would win on appeal as this operation has not yet been accepted by Medicare or the AMSBS. But maybe you would win, who knows. If you were to appeal for the DS, your chances of winning would be excellent, but only you can determine which operation you want.

 

Larra

I also have pacificare HMO, my doctor approved me for the RNY, but after looking on this site my mind is set on getting the DS.  I called the doctor I wanted to do the DS and the insurance person there also called Pacificare and they told her and me that I need to have my PCP send a request to the doctor I want.  I asked them we it covered and they told me yes, as long as my doctor refer me to them.  Alot of people says that I have good insurace , because we have unlimiteed money amount. 




Please let me know what they tell you

I have only been with Pacificare since January 2009 and it's one of the 2 offered by my job. I love my hospital but this is the first road block I am having with them!