Healthnet-Orange County -Dr. Leport

Ok heres the deal.  Ive been working with Dr. Peter LePorts office to have surgery.  For two years Ive been fighting with Aetna (PPO) and they have denied me twice now.  So with the suggestion from the surgeons office I have switched my INS to Healthnet HMO and now I need to find a new doctor in Orange County under The Monarch Medical Group so that I can get a referral and still be able to go to the same surgeon.

Anyone have this insurance and medical group that can refer a good doctor?

I've been having bad luck trying to find a doctor that is not completely ignorant to WLS.



Thanks in Advance!

Melissa

 Sorry to say but most doctors are not pro WLS. I can't tell you how many doctors told me I was too young for WLS, just diet and exercise, blah blah blah. You need to be your own advocate when it comes to getting WLS.

Do you meet NIH (National Institute of Health) criteria for WLS. BMI >40 without comorbid or BMI >35 with comorbids? If you do it should not matter what your PCP's stance on WLS is; if you don't have an exclusion to your policy then your insurance should have to cover WLS.

I would think that getting surgery approved with a PPO would be much easier than a HMO. Because now with a HMO you are going to have to have everything referred from your PCP and then approved by your IPA (medical group) whereas with a PPO your surgeon's office would handle all your insurance stuff. You can go straight to a specialist and not have to go through your IPA, which by the way is sometimes more of a pain in the butt then dealing directly with your insurance company. I know you didn't ask all this.

I have Health Net HMO too, I got approved for the RNY in July but am currently getting an IMR (independant medical review) with the DMHC (department of managed health care) because I'm trying to get approval for the DS (duodenal switch). Once you've exhausted all appeals through your insurance you can ask for an IMR with the DMHC (I think you can only do this with HMOs, not sure though since I've never had a PPO). The DMHC is very pro WLS and usually overturns insurance denials for WLS if you meet NIH criteria. 

I just wanted to let you know that if you qualify for WLS and you want WLS don't let anyone tell you No or stop you. Here are a couple of posts that I hope will help you in your weight loss journey. I hope it goes much faster and smoother for you than it did for me. Best of luck. PS check out all your surgery options and get the surgery you can live with not the surgery that your insurance is willing to give you. Do not settle. I  hope someone will come along and suggest a good PCP for you who will be pro WLS and help you along the way. Even if you can't find one who is for WLS you can still get insurance approval. Neely


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I did not have Healthnet, but I did have Monarch Medical Group and was approved within a week. PPO was Ann Newsome in Garden Grove 714/537-7800.

Hi Melissa,

I have Healthnet HMO and Monarch, my PCP is J. Margo Jaffe Orr, she is located in Rancho Santa Margarita and I highly reccomend her.  Her # is 949-709-0988.  If you have any other questions let me know.  I also went through Dr. Leports office and my surgeon was Dr. Ali.  He is wonderful!


Nancy