How Pushy is Pushy

on 11/13/21 12:30 pm

Hi DS'ers,

I had DS surgery about 1 1/2 years ago now and it's great. I now have Kaiser in SoCal and they are giving me major push back on my labs. Basically they are not wanting to do all labs requested by Dr. Keshishian, and just being hard to work with in general. To be clear, I did not go thru Kaiser for DS surgery and paid out of pocket. But I am wondering if anyone know how hard I should advocate for myself regarding this issue, it really does **** me off, just seems unreasonable. Is it worth it to switch to another insurance provider, or fight harder, or pay out of pocket? Any who has dealt with this issue, please chime on in.

White Dove
on 11/13/21 5:08 pm - Warren, OH

When it is my health that is being compromised, I will pay out of pocket and argue with the insurance company later. Most of the time, if your surgeon writes an appeal explaining why the tests are needed, the company will back down and approve.

It is worth looking into another health insurance plan to see what they will cover and decide if switching is right for you.

Real life begins where your comfort zone ends

on 11/13/21 6:54 pm

Thank you! That is very helpful, I can suggest this to Dr. K.

on 11/16/21 9:32 pm - CA

I don't know if Kaiser has the provision to reimburse you for outside charges (probably difficult as they like to do everything themselves in house.) I suspect that this is one of those situations where they need to be "trained" on what you need, and once that is done, it should go easier the next time. Would Dr. K be willing to call your primary doc there and explain to him why these labs are so important (and how it will save them in the long run)? Failing that, it may be worth trying to go through it the hard way with their multiple appeals, documenting their necessity.

Kaiser is certainly not a DS friendly group, as they don't have the ability to perform them in house, but quite a few have had them done in their ticket after the appeals get to the state level and they are directed to cover it, so they can be familiar with what is required for it. One of the guys in our SoCal support group (loosely taken over by Dr. ****il covid hit and everything went virtual) had a DS that SoCal Kaiser revised (lengthened his common channel), so they do know how to treat DS patients, but you may have to rub their nose in it to get them to respond.

In short, it is probably worth the effort to be pushy, but if it is too much for you, then it may well be better to go with another insurance provider. My wife has had little problem getting her annual labs done with the carriers we have had (PPO type coverage) even though she was a self pay on her DS (from the "investigational/experimental" days.)

Good luck, and be a squeeky wheel.

1st support group/seminar - 8/03 (has it been that long?)  

Wife's DS - 5/05 w Dr. Robert Rabkin   VSG on 5/9/11 by Dr. John Rabkin


* Nicole *
on 11/24/21 5:29 am

I would ask what codes are they using for the lab work. Alot of ins likes to push back on anything WLS but usually if the codes are vitamin deficency and malabsorption its not so much of an issue.

But in short Kaiser just sucks in more ways than one.

DS Aug 15th,2005 @ goal, living life and loving it.

"An Arabian will take care of its owner as no other horse will, for it has not only been raised to physical perfection, but has been instilled with a spirit of loyalty unparalleled by that of any other breed."

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