need help navigating approval process

hi
i'm new to oh, & quite frustrated right now. i have anthem blue cross hmo, lakeside med group for my insurance. i need your help.

in may, my primary doc recommended wls surgery, and sent a letter to my 'group' to request approval. #1

i was approved for an initial consult with a weight loss specialist, who asked for some documentation on my history of weight loss attempts. i was able to give him 1+ years' worth of Weigh****cher weigh-in books, and he wrote a letter recommending surgery. #2

i was approved for a consult with an endocrinologist, who ordered lab tests, then sent the results along with a recommendation for surgery. #3

i received a denial for her (dr #3) request for consultation with a bariatric surgeon (quilici), BUT got approval for a consult with another doctor.... i thought it was just an out-of-network problem, so made an appointment with the other doc, and when i went to the appointment, the secretary was all confused about why i was there..... it turns out this doctor (lewis) is a weight-loss doctor, with his own program. he doesn't DO weight loss surgery recommendations!!

i FREAKED!! here, after all these months, i thought i was finally getting close to getting approval for the surgery, and now i can't  get any information out of the admin office for lakeside. i've called 4 times, talked to 4 different people, and all they tell me is it is 'pending additional information.'
they won't tell me WHAT information, or from WHOM!!

i'm getting really upset and worried that they will turn me down - although i should qualify. i'm over 100 pounds overweight, have co-morbidities, and 3 doctors who've recommended this!! what more could they want?!

has anyone had any experience with this sort of situation?
any advice on how i should proceed?

thanks!!

Hi Sandra,

Don't be discouraged, it will happen. I have Blue Cross/Anthem Hmo, too. But I have Gateway/Chapman Medical Center. You might want to think about changing to a different medical group. Originally, I had Talbert Medical Group, they sucked!!!!! They would not approve or refer me to any WLS Dr.s. But then I switched to gateway, my neighbor recommened my my primary care Dr. and he then referred me to my WLS Dr. I started to see my primary care Dr. in September 2007 and by December of 2007 I was approved for the surgery. I had my RNY on January 16, 2008. For me, it was a real easy process. If you have any questions, please email me or PM me.

Best of Luck,

Julie

Sandra,

I have Blue Shield HMO and I learned through this process an interesting thing about how HMO's work.  In my case, and probably in your's too, the carrier (Blue Shield in my case) pays a certain amount of money to the medical group (John Muir in my case) to manage your healthcare.  So even though the carrier recognizes certain surgeons & hospitals in their networks, the HMO rules the roost. 

Again in my case, I wanted to have my surgery done at John Muir in Concord who has a Bariatric Surgery program.  Dr. Chin who would have been my surgeon is a contracted provider under Blue Shield to perform surgery, and John Muir Concord is also a provider BUT John Muir Network, my medical group (yours is Lakeside) DOES NOT contract with either their own hospital or their own Dr Chin for Bariatric surgery.  How crazy is that!  So, I have a wonderful relationshp with my Dr. who is a very straight shooter, and he told me it's all about saving a buck!  John Muir Network can save their money that Blue Shield gives them for my care, by sending me to UCSF for my RNY because it costs them less money!  They don't give a care that I have to drive an hour and a half for all my Dr. visits etc. vs. 15 minutes.  I even challenged it with the CA Dept of Managed Health and basically I was told that's the way it was.  At that point, I researched UCSF and found out it was one of the top 10 hospitals in the nation and Dr. Rogers has a great reputation and I have really been happy.  Interestingly enough, a nurse case manager calls me prior to surgery from John Muir, she sends me all sorts of info on post op care, which was totally contrary to the way UCSF does things.   I go into even more detail on my blog about this journey.

So that's what I found out about HMO Networks.  I hope it helps with your frustration.  It helps to understand the game.  But fear not, make friends with Lakeside and tell them you need to talk to someone who would do the authorizing of your surgery so that you can find out who you need to see to get this thing going.

Best of luck, don't despair, keep us posted.

Always,
Barb

What Barb says is correct.  The Insurance companies pay Capitation to the Medical Groups for each person covered by them who belong to that medical group, whether that person is ever seen or not. ( I hope that makes sense)  The idea being that there will be enough people not seen and paid for to make up for those who are seen.  The Medical Group has control of your treatment for the most part then.  If you've been denied seeing a doctor, the Medical Group denied you.  You have the right to appeal that denial with the Insurance Company though and they can override the Medical Group.

We had to do this several times with my husband's surgeries and each time we were lucky enough to have the Insurance Co overturn the Medical Group's denial.  The Insurance Co has 30 days to resond to your appeal.  I know this is a long drawn out process and to be honest it sucks, but I'm sure others here can tell you about their battles to get WLS.

You may want to change Medical Groups like the other poster said too.  Some are much better than others.  I hope this helps.

thanks to shopgirl, munchkynn, liz r & barb2 for your supportive responses..
i've had a crazy week, my first grandson was born yesterday, after a very long & difficult labor.

i did finally hear back from the med grp, they said the 'additional info' they needed is bmi & documentation of supervised weight loss program. all this should be in  my file, it was provided to the 1st doc who evaluated me.

i will try and make friends @ the med grp - it seems like the last guy was at least interested in trying to do a good job, & not just pass the buck. i did send them the info they requested, & will cross my fingers.

thanks again for your help

 Don't even bother with your medical group. Do not believe when someone says they "want to help you." Insurance/ medical groups are a business they are out to make money. 

What you need to do is appeal directly to your insurance.  Tell them that you've been to three different doctors and they have all recommended that you get WLS. Provide the letters, along with documentation of your cormorbidities, documentation the you've done weigh****chers for x number of months and request that they refer you to a bariatric surgeon.

In the state of CA you don't have to do the 6 month supervised diet. I think your medical group is trying to make you "prove" that you are commited to losing weight. Don't let them get away with this. The appeals process usually takes 30 days. If your insurance denies you, appeal again. After you've exhausted all your internal (i.e. insurance appeals) you can request an IMR (independent medical review) with the CA DMHC (Dept. of Managed Health Care). They are very pro WLS and will overturn your insurance denial. 

Do not give up. After your first appeal, your insurance should make your medical group refer you to a bariatric surgeon. If they won't refer you because of the 6 month diet go to this link:
http://www.obesityhelp.com/forums/insurance/3697418/CALIFORNIA-NEWBIES-and-PRE-OPS-LOOk-HERE/#29625498

http://www.obesityhelp.com/forums/CA/3825604/process-puzzled/




PS: make sure you research all your options for WLS. Check out all the forums on OH: DS, RNY,VSG and Lapband. Feel free to PM me if you need help.  Best of luck.

oops - sorry for being a bit terse - i was interrupted by my son's dog...
the baby is gorgeous, & worth the wait, but it was all very stressful & worrying, waiting for him, hoping everything waswould be ok. they are 1st time parents  & he's my 1st grandbaby, so we've been pretty focussed on his arrival.

i can now get my head back into the game of approval - & it sure feels like a game!
anyhow - i will stay focussed on what i have to gain/lose from 'winning' this game, & persist in staying calm & positive.

thanks again everyone!

thanks neely2cute for  your practical advice.... i know they're out to make $$$, but i'm such an idealist, i keep hoping people will 'do the right thing.' i think i will appeal to my insurance - they are the ones who are the bottom line.

i really appreciate everyone's support.

thanks again! it's good to know i have allies

Neely is right, don't bother appealing to Anthem Blue Cross or your medical group. Lakeside is notorious for delaying aprovals for bariatric surgery (my doctor put in for a referral in 2002 and I didn't get it until 2004 and then I still didn't have surgery!). Do yourself a favor and look at the Anthem/Blue Cross requirements for bariatric surgery. Get ALL of the documentation you need, write a good appeal letter (let me know if you need help with this), and file an IMR with the Department of Managed Health Care. It can take about 30 to 45 days to get an answer, but as long as you meet the requirements of the insurance, you're pretty much guaranteed that DMHC will over turn the denial by Lakeside.

The important thing to remember is that you need to do your research and be sure of what you want and what is right for you.. what you can live with for the rest of your life.

As an aside, I used to be like you.. altruistic and believing everyone really *wanted* to do the right thing. Problem is, I ended up getting horrible screwed thinking this way. My medical group denied auths 11:1.. I lost my vision, suffered brain damage and had to fight for over 6 years to get my DS and finally I filed an IMR and DMHC found in my favor in a month.

Anthem Blue Cross HMO is another one that's notorious for messing with their patients, delaying auths (or just denying them outright), and making excuses with a smile.

I'm not going to push a DS on you or anyone (even though I think it's the best procedure available) because it's not for everyone. But you have the right to choose what's best for you given your unique health factors.

Also as a last aside, my step-mom had RNY with Quilici in 2003, and never lost to goal, has thrown up EVERY DAY since surgery with anything and everything she puts in her mouth (other than Cheez-Its) and has now regained 50 pounds in the last 9 months. She wasn't given instructions on follow-up care, and was only told to take 2 chewable children's vitamins a day and a B-12 once a week for the first 6 months post-op. I'm hoping he's made a LOT of changes, but I can tell you that I thought he was a jerk back in 2002 when I saw him, and even more of a jerk when my friend went to see him last Summer/Fall. Don't settle, and demand respectful treatment of whatever surgeon you choose to go with. There ARE options, and you have a right to have them available to you.

I wish you the best of luck!