My Journey...
Count one more reader! 
My story bears so many similarities to yours, Jonne, it's uncanny! Pardon the long post, but I think you'll find this interesting.
In my case, my journey began in October or November of 2004. I had gone to the WMC at St. Charles as a "diet only" patient. At the time, I worked for LSU and had Definity for insurance (that's the over-hyped "consumer-driven" plan). Even without planning on having surgery, they recommended most of the pre-op tests, including a sleep study. I had all my tests in December, then the sleep study around Christmas time at St. Charles, and it was actually the last sleep study they performed before closing. During this time, I was seeing the dietitian, who had me on the "modified fast" diet -- 2 protein drinks and one small low-carb meal per day. I was waiting to see Dr. Raum so that I could be cleared for the all-liquid diet.
Between January and March of 2005, I had placed many, many, MANY calls to the WMC staff at Touro to find out when I could get an appointment to see Dr. Raum and finally get cleared for the full fast diet. At the time, the providers were going through the transition of changing their hospital affiliations and working out the details of their contracts. They saw those patients who were already being processed for surgery, but patients like me were not being seen at the time. According to one provider (whose name I won't disclose) they did not see patients for several months, "we weren't going to work without getting paid." (I can't blame them for feeling this way, but...)
I finally saw Dr. Raum in March or April of 2005. At that time, he reviewed my tests and recommended surgery because I had high cholesterol, fatty liver, and severe sleep apnea. About the OSA, he commented, "yes, these levels are not conducive to life." While I am glad to have found out why I overslept so much and was so darned sleepy all the time, I was more than a little peeved that it took them three months to inform me of the fact that I had this serious condition of life-threatening magnitude. I probably would have said something then, but I was also very shocked at the prospect of having surgery. Not long afterwards, I warmed up to the idea.
In April and May of last year, I proceeded to have the rest of my pre-op tests, as well as the psychological evaluation. By the end of May, my case was to be evaluated by the treatment team to give me official clearance for surgery, then the "patient advocate" was going to send it off to the insurance company. I was to spend the entire month of June overseas visiting family, but I made sure I could be contacted (I have a GSM "world phone" that allows me to roam internationally -- it's expensive, but worth it).
Over the month that I was gone, I called every 4-5 days to check on the status of my case. For several weeks, I was told they were waiting on various reports. Then, I was told that the patient advocate was putting together my file for submission to Definity.
When I returned to the States a month later, I found out that my file had just been sent out to the insurance company! About two weeks later, I was told that insurance denied my request because they had just enacted an exclusion for WLS that month! I was told that all state employee plans now had that exclusion, and there was no way I could have my surgery covered unless I were to switch to some other insurer. Seeing as I could barely afford my state group rates, I was certainly not in any position to switch insurers.
At that point, I pretty much gave up on surgery and joined Weigh****chers for the 1239034915th time. Then, after the "Big K" hit, I just stopped caring about weight loss completely. I was also having a hard time keeping up at work and had too much to worry about besides surgery. In April, I started to consider going for surgery again. I have BCBS Federal now, and WLS is approved if "medically necessary." Since I live in Slidell now, I decided to go with Southern Surgical Specialists, specifically Dr. Moore, who was listed as a preferred surgeon. Unfortunately, after a couple weeks, the patient advocate informed me that their practice is not "preferred" for bariatric surgery. My only choices were the surgeons at Methodist, which is no more, or Ochsner. So I decided on Dr. Kennedy -- so far, so good.
Unfortunately, I'm still having problems with Dr. Martin's staff. It's now been close to 4 weeks since Dr. Kennedy's office requested my records from them, and they still haven't arrived -- even after they were re-requested a couple weeks ago. While waiting, I re-took most of my pre-op tests. I'll have a repeat psych eval tomorrow, and the psychologist estimated a one-day turnaround on the report. Unfortunately, my sleep study is among the records we're awaiting, but I have statements from the company that rents my CPAP machine, so we'll submit those to document my OSA diagnosis. Hopefully, my case will be submitted to insurance by the end of the week -- without my old records.
So, basically, it was because of Dr. Martin's staff's slowness that I couldn't have surgery last year, and it's because of their staff's slowness that my surgery is being delayed this year. Don't get me wrong -- they're very nice, polite people. Unfortunately, they draaaaaaaaaaaaaaaaaaggg so slooooooooooowwwwwwwwwwwwwly that I've found it better to avoid dealing with them completely, even at the expense of having to repeat testing.
Best of luck in your journey!
My story bears so many similarities to yours, Jonne, it's uncanny! Pardon the long post, but I think you'll find this interesting.
In my case, my journey began in October or November of 2004. I had gone to the WMC at St. Charles as a "diet only" patient. At the time, I worked for LSU and had Definity for insurance (that's the over-hyped "consumer-driven" plan). Even without planning on having surgery, they recommended most of the pre-op tests, including a sleep study. I had all my tests in December, then the sleep study around Christmas time at St. Charles, and it was actually the last sleep study they performed before closing. During this time, I was seeing the dietitian, who had me on the "modified fast" diet -- 2 protein drinks and one small low-carb meal per day. I was waiting to see Dr. Raum so that I could be cleared for the all-liquid diet.
Between January and March of 2005, I had placed many, many, MANY calls to the WMC staff at Touro to find out when I could get an appointment to see Dr. Raum and finally get cleared for the full fast diet. At the time, the providers were going through the transition of changing their hospital affiliations and working out the details of their contracts. They saw those patients who were already being processed for surgery, but patients like me were not being seen at the time. According to one provider (whose name I won't disclose) they did not see patients for several months, "we weren't going to work without getting paid." (I can't blame them for feeling this way, but...)
I finally saw Dr. Raum in March or April of 2005. At that time, he reviewed my tests and recommended surgery because I had high cholesterol, fatty liver, and severe sleep apnea. About the OSA, he commented, "yes, these levels are not conducive to life." While I am glad to have found out why I overslept so much and was so darned sleepy all the time, I was more than a little peeved that it took them three months to inform me of the fact that I had this serious condition of life-threatening magnitude. I probably would have said something then, but I was also very shocked at the prospect of having surgery. Not long afterwards, I warmed up to the idea.
In April and May of last year, I proceeded to have the rest of my pre-op tests, as well as the psychological evaluation. By the end of May, my case was to be evaluated by the treatment team to give me official clearance for surgery, then the "patient advocate" was going to send it off to the insurance company. I was to spend the entire month of June overseas visiting family, but I made sure I could be contacted (I have a GSM "world phone" that allows me to roam internationally -- it's expensive, but worth it).
Over the month that I was gone, I called every 4-5 days to check on the status of my case. For several weeks, I was told they were waiting on various reports. Then, I was told that the patient advocate was putting together my file for submission to Definity.
When I returned to the States a month later, I found out that my file had just been sent out to the insurance company! About two weeks later, I was told that insurance denied my request because they had just enacted an exclusion for WLS that month! I was told that all state employee plans now had that exclusion, and there was no way I could have my surgery covered unless I were to switch to some other insurer. Seeing as I could barely afford my state group rates, I was certainly not in any position to switch insurers.
At that point, I pretty much gave up on surgery and joined Weigh****chers for the 1239034915th time. Then, after the "Big K" hit, I just stopped caring about weight loss completely. I was also having a hard time keeping up at work and had too much to worry about besides surgery. In April, I started to consider going for surgery again. I have BCBS Federal now, and WLS is approved if "medically necessary." Since I live in Slidell now, I decided to go with Southern Surgical Specialists, specifically Dr. Moore, who was listed as a preferred surgeon. Unfortunately, after a couple weeks, the patient advocate informed me that their practice is not "preferred" for bariatric surgery. My only choices were the surgeons at Methodist, which is no more, or Ochsner. So I decided on Dr. Kennedy -- so far, so good.
Unfortunately, I'm still having problems with Dr. Martin's staff. It's now been close to 4 weeks since Dr. Kennedy's office requested my records from them, and they still haven't arrived -- even after they were re-requested a couple weeks ago. While waiting, I re-took most of my pre-op tests. I'll have a repeat psych eval tomorrow, and the psychologist estimated a one-day turnaround on the report. Unfortunately, my sleep study is among the records we're awaiting, but I have statements from the company that rents my CPAP machine, so we'll submit those to document my OSA diagnosis. Hopefully, my case will be submitted to insurance by the end of the week -- without my old records.
So, basically, it was because of Dr. Martin's staff's slowness that I couldn't have surgery last year, and it's because of their staff's slowness that my surgery is being delayed this year. Don't get me wrong -- they're very nice, polite people. Unfortunately, they draaaaaaaaaaaaaaaaaaggg so slooooooooooowwwwwwwwwwwwwly that I've found it better to avoid dealing with them completely, even at the expense of having to repeat testing.
Best of luck in your journey! 
Thanks Diane!
But what makes you think this? Because I am a Medicare patient, it doesn't matter whether I have Tenet or Humana, it's Medicare that is insisting that the WLS be performed at a "Center For Bariatric Excellence". There are only three in Louisiana, one in Lafayette and two in Shreveport.
Jonne
Jonne,
this is not something I've put out there much...yes I am considered disabled...at 458 lbs I couldn't walk to the freaking mailbox let alone anywhere else. I researched the different insurances when I got medicare and I found Humana gold plus to be the easiest.
In fact my approval was received the same afternoon they asked for my surgery to be performed.
Maybe it is because Dr. Ordoyne isn't a 100% of the time bariatric surgeon.
It would not hurt for you to attend his seminar, talk to his insurance girl and make a decision.
Medicare played no roll in my surgery. The way I understand it once you choose a provider - tenet/humana/BCBS they become your sole insurance. They only agree to cover exactly what Medicare would cover.
Diane,
Would you e-mail me his info...please!
Jonne [email protected]
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