CALI QUESTION!

Does any one have anthens blue cross hmo,

I was just wondering if the stuff im going through is on the right track, or if I have more to look forward to

Sorry, I was Blue Cross PPO and didn't have a speck of problems, wishing you luck.  Don't give up either.

Diane

 Where are you in the process? What are you going through? All HMOs are different because it really depends on your medical group and primary what is required to get approval for consult then bariatric surgery. Since you have a HMO everything must first get referred by your PCP then it goes to your medical group, if you don't agree with their decision then you appeal to your insurance.

If you have a supportive PCP your journey may be easier and shorter than most people. But just to let you know that since you are fortunate enough to live in CA you have certain rights that other people in other states do not have. We have the CA DMHC (dept. of managed health care) they are a state agency that oversees HMOs and are very pro WLS. 

I had to struggle for over 5 years to get insurance approval so if you are facing problems feel free to PM me and I will help you as much as I can. Insurance companies are evil and they need to pay lol. Best of luck

Well, I went to my Pcp and she gave me a referral on 11/21/08 but I didn't find out until 12/15/08 that I had to call and get a appointment  so, I called got an appointment for ( drum roll) 3/09/09  what that appointment is for, I have no idea. I got some papers in the mail they told me to fill them out and then send them to the offfice Immediately if I get them in early and someone cancels then they will bump me up to a date closer.

My medical group is THIPA and its in torrance california, I went on their website and they stated something about doing a 6months diet plan and im like not another one or better yet 6 months,

 You have every right to know what the appointment is for. Call up your medical group, it should be on your insurance card, and ask them. If it is an appointment to do a six month diet. Then make an appointment with your PCP and ask her to submit for consult with a bariatric surgeon now. You do not have to do the 6 month diet or lose 10 % of your weight before getting referred for a consult or getting WLS.

Please read my thread on this topic here:
http://www.obesityhelp.com/forums/CA/a,messageboard/board_id ,4806/cat_id,4406/topic_id,3825604/action,replies/

http://www.obesityhelp.com/forums/insurance/a,messageboard/b oard_id,5363/cat_id,4963/topic_id,3697418/action,replies/pag e,1/#29625498

OMG!! so here is the information that I recieved, I spoke to the medical group the proccess for getting the surgery is 8months, I have to get all my test done, do weigh in, lose 10 pounds before gettign the surgery and I have to go to 2 supporty groups a nutirition class so they said, if I have a  appointment for 3/9/09 I could be looking at surgery in november!!!! what the hell is that. does the test take that much time?  I read your blog and Im wondering what else to do cause Im  thinking of changing my pcp and medical group cause the rep for this medical group said every medical group is differnt.

 Calm down. If your PCP referred you for this class or program then she is probably pro WLS. Just because you change medical groups does not mean that you won't encounter the same bureacracy. Like I said before Medical groups/ insurance/ are evil and will do anything to deter you from getting WLS.

Please print out the peer review that I gave in my post and also print out the DMHC IMR decisions. Take them into your PCP and explain to her that you don't have to do the medically supervised diet. That there are no published studies or peer reviews that state that the diet is beneficial. Ask her to refer you to a bariatric surgeon NOW. Let her know that you know that it will be denied by your medical group but that you will then appeal to your insurance, if your insurance denies then you will file a grievance with the DMHC. If  you have the medical criteria from  your insurance take that in to her to see too. If the only thing you are missing is the supervised diet (and again the diet is not required in the state of CA) she should refer you. 

Every insurance rep you talk to and every person at the medical group will tell you different things. If you know the criteria that your insurance requires and the only thing you do not meet is the diet then do as I stated above. 

All that being said. It will still take you a few months from now until your actual surgery. This process will just make your referral to the bariatric surgeon come now and not 3 or 6 months from March. Once you get the referral to the bariatric surgeon you will still have to attend their seminar before you actually get an appointment to see the surgeon. From there the surgeon will order labs and pre-op tests that you need. You will have to go back to your PCP and ask them to refer you for those tests. Depending on your medical group, it will take time to get the appointments for the test. Everything takes time. You can not rush the process. 

I would suggest that you tell your PCP that you are still willing to see her in the meantime while you wait for the referral with the bariatric surgeon. If you can afford to pay for a nutrionist on your own and see them monthly as well. Even though you don't have to do these things, in the long run you are better off doing them so that when you finish all your pre op tests and requirements you'll also be done with the diet too. You don't have to do anything I've said and it still will be overturned by the DMHC if your insurance denies you based on the diet. But that's what I did and it really takes your mind off all the waiting.

You should attend support group meets. It is beneficial to meet actual people who have had surgery and see what their post op lifestyle is like. You get support here but it is different from meeting people in real life. It is also beneficial to see a nutrionist who spealizes in bariatric patients because you need to be ready to change your eating habits, take vitamins, and who better to tell you about these things than a nutrionist?

Sorry the response is so long. I hope that it is helpful and feel free to PM if you still are in need of help.

lol ok, I took a chill pill and relaxed and realized that everything is a proccess and what you said about the nutrition classes and the support groups makes since and if Im going to make this a life style change and not a quick fix I want to do it right.


Thanks for your information and responding.