Healthcare Partners IPA Reqs?

Hi - I am looking at switching IPAs to get an authorization for surgery at USC.  My current IPA doesn't contract with them, and I really want Dr. Crookes to be my surgeon. Does anyone know what Healthcare Partners' requirements are for bariatric surgery, specifically for the DS?  My insurance carrier is Blue Cross, which covers the DS, and is apparently very easy to work with if your IPA is easy.   I have contacted a doc (Theresa Woehrle) to find out if she will take me as a patient.  Does anyone know her? Thanks! Aimee :)

I HAD Healthcare Partners and I am having Dr Crookes do my WLS on June 4th, just got approved on Good Friday. Generally HealthCare Partners require...... Psyche Eval, 6 month diet program,stress tests, referral from PCP, BMI of 35 with at least 2 co morbities or a BMI of 40+, a sleep study and blood work. You actualy HMO provider may have other requirements or NOT require the same as HCP. I HAD BC HMO and they did NOT require a 6 m,onth diet, so HCP could not require it. I am going to be brutally honest here..... Healthcare Partners DOES NOT like to refer to USC they use a Dr in Torrance. She very well qualified adn very nice BUT I wanted Crookes and it took 2 months and pushing real hard to get a referral to USC, I did get it.  I had nothing but trouble with my PCP and HealthCare Partners, Once I switched to a PPO I was approved within 6 weeks of switching. I can give you some tips on dealing with Dr Crookes office too if you need them. there is an art to it. MY ONE piece of advice is get a PPO and eliminate all other from making life decision FOR you. PM me we can talk offline if youd like. I worked in Corona in 9 years was just there yesterday. Good Luck

Oh dear....  Bummed out! General question for the board, and then lots of private questions directly: What do you mean by "I  HAD BC HMO and they did NOT require a 6 m,onth diet, so HCP could not require it." When I called Blue Cross (and I have the HMO - CaliforniaCare), they said that they let the IPAs set the rules to determine medical necessity and that I could appeal it if declined.  NOT that the rules for BC trumped the rules set by the IPA.  My current IPA is PrimeCare of Corona and they're requiring me to lose 30 pounds which is rediculus.  (I'm on insulin and a lightweight!) How did you go about getting HCP to back down?  Thanks for your help, and lots of questions offline to come! Aimee :)

Well, the good news is that you reside in CA and can dispense with the insurance NONSENSE- requirement for a 6 month medically supervised diet. Short of having your surgeon having his OWN requirement for some weight loss, and assuming you have met all the other requirements, there is really no reason you need to be saddled with this. Below is a modified post from my friend Diana, an Attorney not specifically identified as an expert in insurance, but very knowledgeable and helpful in this area to countless others in our weight loss community .
I would ask your doctor to submit your request for WLS NOW and get the denial for lack of doing the six month diet, and appeal.  But instead of JUST appealing through the insurance company's internal review process, after you get the FIRST denial, I would get the forms from the DMHC and file a GRIEVANCE, not a request for IMR (Independent Medical Review), to get them to force your insurance company to drop the diet requirement.

Here is the DMHC document that establishes that there is no proper basis for requiring a diet:

http://www.hmohelp.ca.gov/boards/cap/bariatricrev.pdf

SUMMARY CONCLUSION

There is no literature presented by any authority that mandated weight loss, once a patient has been identified as a candidate for bariatric surgery, is indicated. There is a mixture of results that question whether weight or truncal obesity is a risk factor for complications after bariatric surgery. The more analytic studies have not found that body mass index (BMI) or total weight is an independent risk factor for complications or death from bariatric surgery.

No institution that has recently published data on bariatric surgery describes a protocol requiring weight loss between identification of the need for surgery and the surgery. Many institutions in California have published results of surgery with particular focus on factors that contribute to morbidity and mortality. No paper from a California institution mentions mandated weight loss before bariatric surgery. Nor does any literature regarding the treatment for the morbidly obese recommend continued weight loss during the period between identification of the need for bariatric surgery and the surgery.

Mandated weight loss prior to indicated bariatric surgery is without evidence-based support. Mandated weight loss prior to indicated bariatric surgery leaves the patient at increased risk from the patient’s comorbidities. Mandated weight loss prior to indicated bariatric surgery is not medically necessary. Mandated weight loss prior to indicated bariatric surgery would be deviant from the standard of care practiced in the United States and other published countries. The risks of delaying bariatric surgery, while not entirely known in the short-term, are real and can be measured. Any potential value of losing weight prior to bariatric surgery is theoretical and not supported by any data. An experimental study including fully informed consent to determine if there were a reduction in risks or other benefit from mandated weight loss prior to bariatric surgery is indicated.
Good Luck! Rock

This is sooo awesome. Thank you so much for this.  I have an appt with my PCP tomorrow morning and will wait to get my denial. Best, Aimee :)

I also had Cali Care and THEY do not require a 6 month diet program to get approved. My medical group was Magan in Covina, they knew very little about bariatric surgeries so they followed what BC said. I got HCP to back down by doing my business face to face with the HCP rep at Magan, it very hard to say no in person  The Dr they wanted to send me did NOT do the VSG so why waste time and money going to her was my angle to get to USC, I wanted the VSG and she only did the RNY or Lapband. I also checked with USC to make sure they were accepting HCP patients, they still are. I pushed and pushed and pushed I was a big pain in their ass until I got what I wanted. I am sure it sucked dealing with me BUT in the end I know whats best for me and would not accept anything less.

This thread has been hugely helpful for me.  I too have BC Cali. Care HMO with a practice management group (Hill Physicians) and a PCP that ate trying to require failure on a 6 month doctor supervised diet prior to giving me a referral to even consult with a bariatic surgeon.  Great idea to push for approval without the diet and get a denial and file a grevience.  However, I dont understand how the DMHC document helps this.  Could you please explain it to me? It seems to addres the surgeons requirement of weight loss prior to the surgery not the failure on the supervised diet as a requirement for being a surgery candidate.  I would also love to hear how people got their PCP to go witht he BC requirements over the groups requirement.  Thanks, folks. 

Oh, it's clearly applicable to the insurance companies requirement. Suffice it to say, they are getting this diet requirement nonsense overturned right and left, including, Kaiser's options program.

You can see some of the recent cases overturning this requirement for yourself. http://tinyurl.com/2edten Rock

Rock - ah haaaaaa, now I get it! Thank you soooooo much! This info is going to make such a difference to my case. My printer is practically smoking with all the supporting evidence you pointed out to me. I am meeting with my doctor in the morning and I will be armed up to the eyeballs. I am deeply (and cheerfully) in your debt. Thank you, thank you, thank you! D2K

You're entirely welcome and good luck. However, the credit should really go to my friend, Diana. Let us know how things go with your visit to your doctor's office and good luck.

Rock