Lost my surgery date in November

Dear All: I had a date of November 18, 2003 but the story is long. I lost the date because of Dr. Szomstein's insurance person, Anita. If going to his office he comes across as warm, caring and professional. I am not critizing that nor his ability. However, if one only knows someone for 15 minutes judgement is difficult. I did feel confident but ultimately they hire and fire their staff. I must vent a bit. I am sorry because this is long. Yesterday was bad enough but today was worse. Yesterday, I received a letter from the insurance company (CIGNA) rejecting me for Gastric Bypass Surgery for the second time, the letter was dated October 9, 2003. However, there was still an option that the doctor could utilize if he wanted. I was told today by Carmen that only Anita, Dr. Szomstein's insurance person, does that and I would have to wait. I have waited and the trust in this area of the office is lost. The reason for the first rejection was dated October 2, 2003, which was the very day I called Anita, the insurance person for Dr. Samuel Szomstein's office, to see if she had sent in the insurance information yet. She said it was on her desk and she was going to work on it that day. The first rejection letter read, "After a review of the information submitted, we are unable to substantiate medical necessity for requested procedure/services(s). In order to process your request, we will need the following additional information: letter of Medical Necessity, lab work appropriate to diagnosis, recent medical history and physical, and documentation of: Nutrition consult, two supervised weight loss programs with weigh-in's at least monthly while in the program; attempts to medically manage comorbidities. Must receive within 30 days." I was very shocked by the letter because Anita had been doing this sort of coordination for some time and knows what must be sent. The second rejection was addressed to me and dated October 9, 2003. "CIGNA Criteria requires documentation of compliance with one recent physician directed weight loss program. An acceptable weight loss program includes all of the following physician directed components: Dietary therapy (low calorie diet); Increased physical activity (exercise program); Behavioral therapy to reinforce dietary and increased physical activity; Consideration of pharmacotherapy with FDA approved weight loss drugs. Diet programs/plans alone, such as Weigh****chers, Jenny Craig or similar plans, are not considered physician directed weight loss programs as outlined above. Physician directed programs consisting exclusively of pharmacological management are also not considered acceptable physician directed weight loss programs as outlined above. Because the above criteria was not met the request for Bariatric Surgery is denied." .... Anita called me on October 10 to tell me that the insurance company requested medically supervised diet charts and Weigh****chers, Jenny Craig, etc. Therefore, I told her I would gather these items immediately. That very night my former Family Nurse Practitioner faxed me a letter that evening, and one of the Doctors was out of town until Wednesday, October 15, 2003. Another Doctor is out of town with is ill father. Then on Monday, October 13, 2003, I received a call from the doctor who was out of town on business. He asked a number of questions that I answered regarding where I was having the surgery, the other clearances that I had had. He knew my medical history because he was my OB/GYN for many years. He is no longer my doctor due to insurance changes. He dictated his letter to his office, they faxed to me, and I scanned it through ADOBE and sent is as an attachment to Anita, late on October 13, 2003 because it arrived to my fax at 3:24 PM from Baptist WNS Health 305 595-3526 (which is printed on top of Dr. Spencer F. Kellogg's letterhead). During this time, emails were exchanged between Anita and me. She stated via a phone conversation that emails were not accepted. I explained that these were actually letters that were attached and she needed to print them out and send them to the insurance company. She said that they would not accept Jenny Craig either. Okay so send the letters, no she says that they had to be charts. I said my charts were in some medical warehouse, which I was told. I wrote emails the evening of October 13, 2003 and received nothing back. I wrote again on October 14, 2003 the following email at 11:23 AM with a copy to Dr. Szomstein: Dear Anita: I am awaiting your reply to my questions. Shall I retain an attorney to contact the insurance company? At this juncture, I am very worried and a bit hyper and anxious. After going through all of this and nothing. Reread the questions of last night's email. DID I lose my surgery date? Should I call the insurance company? What has been sent thus far? I would like to have copies of all that has been sent to present to the attorney, is that possible? Do I need to drive up there from my home to assist or sit down with you? It is a little over an hour and fifteen minutes. Did the insurance company accept the Dr. Szomstein's letter of medical need? Was there supporting documentation? Please let me know, I am also preparing to fax the letters to your office. Should I send anything else? I cannot help the fact that documentation and charts have been sent to storage and usually a summary is prepared by a major company. I do not know about these things. Even all of my brain surgery and neurological things are sent as well. The Weigh****chers items are things that I had and didn't keep. The online weigh****chers was stopped about February of this year. I now wish that I had saved these things but who saves failure. Am I now off the list? Please respond. Karin Brown Late afternoon on October 14, 2003, I placed a call to Anita because the rejection letter arrived and I read it with disbelief because Anita did not mention a rejection only that these letters were asked for by the insurance company. I was told she was not in and would I like to speak with her voice mail. I did, upon hearing her message, "I will not be in the office from 3:30 PM October 14, 2003 until October 22, 2003." I could not believe my ears and made a comment of total disbelief on her recorder. I then decided to call the insurance company to see what could be done. They were surprised too, and Andi "C" consulted with a supervisor, *****layed that I had what was required with those letters and why they were not faxed was something they did not understand. Actually, they commented that I did the work for Anita - and repeated it twice that I did her job and they totally understood my upset. The following could be done according to CIGNA. There is still time for approval. If you and Dr. Beck can see your way clear and get together, he can submit for authorization from CIGNA insurance company. He can put you down as the surgeon to do the surgery. 1) The doctor or nurse should establish a verbal communication to ask for the criteria needs to be done first. 2) Ask for a fax number so the items that need to be presented are presented with the necessary documentation to meet each criterion. Do not send in a sheet here and there. 3) The nurse or doctor needs to call every day or two to establish what else they may need. If this is done tomorrow then there is time for me to be authorized and still fit in needed pre op. procedures. I also wrote to Samuel Szomstein, M.D. the evening of October 14, 2003 a page and a half letter including the CC: to Dr. L. Beck, my Family Medicine doctor and the name of the five attachments of the items that I had provided for Anita, even though these items were given by me for the chart. During the process, I changed my personal history to reflect the changes from the doctors that I was seeing at the Cleveland Clinic. I did request that he call me today, October 15, 2003, and called his office to speak with Carmen. She looked for my fax of the records and letter and said, "I found the five hundred pages." I took offense to this comment as it was all the required items that I have and Anita did not seem to have. There were 22 pages charts, letters from the nutritionist, psychiatrist, Dr. Kellogg, the nurse practitioner, the two rejection letters, and an EKG from February, etc. Carmen stated that it was policy to drop the date, November 18, 2003, that was scheduled for my surgery. I nearly died...I had to speak and was told that I had to listen to her. I had been listening to this office or reading their items, but have found out that the patient does not count here. This was Anita's lack of doing the paper work in a piecemeal fashion as the insurance put it to me. Anyway, I told her I wanted to speak with the doctor and was told he will get to me when he can. She was not going to interrupt his time with patients, which I did not ask for. I never asked her or him to do that. I only ask for the respect that I deserve like the other patients. I stated that I felt if I could get my records (now I find out this is a dollar a page and this isn't my fault but his staff's irresponsibility) Also, I want everything that Anita sent to the insurance company exactly like it was sent with dates. I also asked to speak with the patient advocate...I was connected to another answering machine. I left a message and called again later in the afternoon to Ms. Tammy Soffer. I have wasted my time ... months of my time following Dr. Szomstein's procedures - I am human not a number or the gastric bypass patient in room two. He has spent a total of 10 to 15 minutes in front of me only. At this time, I was even led to believe that my surgery would be late August or early September. He told me that when everything was done to state that I was the person from PTA. Well, so much for that comment. He did not wish to hear it and told me so. So there is no bond --- I was impressed with his warmth and professionalism during that first and only time that I met with him. Now I worry about professional treatment if there was a problem. I have spoken with him twice on the phone and then did respond to a few emails was the only other contact. He never answered my questions and I deserve to have those answered. One of his emails was so curt that I began to feel that I had better keep quiet because he controlled my future regarding dates. When he gave me a date of December 23, 2003, I once again was in disbelief. I accepted it out of fear. Then several friends told me done to allow that because of the holidays and skeletal staff being on duty during those days. Therefore, I let him know. I was called eventually and told that November 18 was the new date and it would not be earlier. Again, I accepted and was most grateful even though the sternness was so prevalent in the voice. Therefore, I did not correspond again until October 2, as I knew my schedule was filling up. I knew of the pre operative appointments had to be made. I wanted to be sure that I allowed some flexibility in my schedule for the doctors I had to visit prior to surgery. Dr. Szomstein had been told by me that I had a PTA State Convention that I had to attend beginning October 13 -16, 2003. In fact, at the first meeting I asked him to speak regarding youth obesity. He said he would like to be considered although he did not encourage surgery for youth. We discussed that a bit during my first and only visit to see him. I am also a very busy person. An oxymoron is that I sit on the State of Florida Obesity Committee and the Food and Nutrition Advisory Committee. I vowed out of the later meeting in Orlando last week because of the insurance problem. I have already given up many things so accommodate this entire process. I would be less upset if I felt things were done properly, even if rejected. But I worked hard and fast to get whatever was needed. If Anita said fax those letters then I would have. At no time did she ask me to do that. Never having gone through this before I leaned on her to know what was expected. I would do it again in a minute if I felt I had a responsible person work with me. At the beginning, I thought I found the perfect place and then I began recognizing the warning sign. The treatment by staff leaves much to be desired. I was told that the doctor would be my advocate for the surgery...well......... He had always said that the insurance company had the last word but he would be my advocate. I now learn the person totally responsible is Anita and she controls my life by her work or lack of work. Well, I am taking one-step at a time, and will do what I can to see what I can do with or with out this office. I no longer have a surgery date ... which has my blood pressure up in fact it is boiling level, and the headaches are unreal. I know it is my upset and stress. Oh well...who cares. I will keep you informed as to the next steps. I am open to suggestions. The insurance company has been very helpful but it is questionable if the doctor wants to advocate. His gal, Anita, has more power and is not questioned from what I have seen, read, and heard. I am trying to find the bright side of this now, but feel more down then anyone will know. Right now I am so bitter that I could not nor will I recommend anyone to the Cleveland Clinic in Weston. Being a midwestern they think highly of the orginal Cleveland Clinic and I know they are fantastic for heart. I do think the world of the Family doctor that I had there, a Harvard graduate and knew that I would make the drive for him. I felt the GYN, the cartiologist, pulmonologist, colorectal surgeon were wonderful. But I question the record keeping, the treatment and respect for the patients in the area of Bariatrics. I have been around doctors for years, we have a number of them in the family, including a son who is a doctor. They are amazed too. Thus far I had not involved them except to ask questions. But asked their opinion on how they would deal with someone who is upset as I am. Their method is not avoidence but to work with the patient and insurance company. Oh well. What am I to do? Love, Karin (Pray that I end up on the lighter side soon and find a doctor who wants to work with me as well as his/her staff)

I cannot believe all the trouble you have gone through! It is ridiculous! I hope that things work out for you and SOON! Keeping you in my thoughts and prayers, Kristen

What you have been through is nothing less than maddening! I have just spent the past 2 years in a very similar situation and mine has finally worked out...Please keep the faith...all of these feelings you are having-I know, I felt the same way, its one of the most frustrating things in the world and you can't know how it feels unless you have to go through it. Please keep hammering at it-that someone will FINALLY get it right and you'll get that date once and for all. Your insurance has specific requirements so you know there can be a GOOD end to this, you know you have something to look forward to, but its frustrating with all these attempts to JUST GET THE RIGHT PAPERWORK SENT IN...boy can I relate! (((((((((((((((((((HUG))))))))))))))))))))))))))

Hi Karen, I read your entire letter and I am totally worn out, I can't believe what you have been through. I have learned through experience if you have that much trouble in the beginning it will only get worse. If possible please find another Doctor, starting over would be better that dealing with his staff. He must be so busy he does not have time to know what is going on in his office. Good Luck I hope it works out for you. Dot W