Getting Approved for Surgery: my 2 cents

(Thanks for the tip Janine....good idea)

Let me begin by saying I know how heart breaking it is to wait for surgery.  I waited a long time to make it to the operating room. The details are in my profile if you want to read all about it.

DON'T GIVE UP, EVER!!!  You can win this fight!!

There are lots of bits of information that I learned along the way and I'm going to do my best to outline them here. If you have more questions, contact me...I'll do what I can to help.

It took me a long time, a good attorney, a lot of patience, and being a bit of a b*tch to get approved. Here is my advice, I hope it helps:

No one is going to fight for your welll-being like you will.  A paper-pusher at an HMO does not have a vested interest in your surgery. They do not realize how hard it is to wait.  To them you are merely a paper/file folder on their desk. I confess that even in my own job in managed healthcare I forget that there are PEOPLE on the other side of all the data and numbers on my desk.

So.....you must be ready to fight.  Be pushy.  Ask for what you want.  Don't take 'no' for an answer. At the same time, be professional, courteous and kind to the people you talk to. Take notes for every phone call you make. Keep all your notes in a binder/folder.  Note the date time and name of each person you speak to and  write down what they tell you.  If they say  "I will fax this on Monday morning" then tell them you will be calling back Monday afternoon to check if it has been done.  Then follow up and call them back.

I think was Maureen who mentioned that a doctor's office told her not to call back, which is STILL kind of making me mad.  What the heck?!  I almost want to call that woman back and give her a piece of my mind!!  Don't be afraid to expect people to do their job. I realize that it takes a while for paperwork to be processed, you have to accept the limitations of these large organizations.  But if you can't get a straight answer, you have the right to escalate your issue to someone higher who can make things happen.  Ask for a boss/supervisor/manager if you think things are not getting done.

ALSO:

Insurance companies that require you to lose weight, see a nutritionist, go to Options classes (like at Kaiser), document your diet for 6 months, etc....are actually stalling you.  The State of California does not require any of thse things to take place before you can have surgery and you an actually appeal these requirements. 

IF YOU NEED TO FILE AN APPEAL - I suggest getting some help, although you can do it on your own.  I went to www.obesitylaw.com and they were awesome.  They were affordable and fought for me like you would not believe.   You will first need to file an appeal with your HMO. By California law they have 30 days to respond to your appeal.  Be very careful that you follow every single one of their guidelines in the appeal process. (This is why an attorney become important)  

If they deny your appeal you can then escalate your appeal to the state.  The Department of Managed Health Care is the state agency that governs over every HMO that operates in the state of California.  They are influential, the mention of their name makes HMOs nervous, and THEY ARE ON YOUR SIDE.  

When my appeal went to the DMHC it was perfect timing.  My insurer Pacificare was up for a renewal of its licencse to practice in California.  My appeal brought to their attention that the were stalling WLS patients.  I wom my appeal and my phone was ringing off the hook with calls from Pacificare telling me to go see my surgeon because I was approved. The DMHC scared the heck out of them!!

I know this is a long post, but others of you who fought like I did PLEASE ADD YOUR COMMENTS.   I think I forgot how hard it was to wait for surgery, I'm so sorry......please let me know if I can help!

THANK YOU THANK YOU THANK YOU THANK YOU THANK YOU!!!!

This is a wonderful piece of information.  Monday morning I have to be out and about and will be stopping by the doctor's office and with a wonderful smile on my face will be asking about the status of my pre-approval!

Thank you for all the wonderful information and helpl

I think one of the most frustrating things about going to the local support group...is seeing over half the people attending being Kaiser pre op patients.  They would run so many people around.  They realized they should have years ago (for their bottomline) excluded WLS...But they didn't.  So in order to protect their assets they had thousands and thousands of people jump through their WLS hoops and most just gave up.  This has happened the last few years.  I heard they were easier about 3-4 years ago.  Thanks Monica.  You might want to post this on the Main Board...I know there are alot of people in that same boat there.  Brian

Hi There,

I am an X Kaiser patient. They ran me around for 1 and half years. Then my husbands Union changed insurance carriers and "VOILA" I had my surgery within 4 months.
One good thing was, I was able to use my medical records from the Kaiser "run around" instead of paying to do it all again.

Good Luck and Fight for Your Right!!

Monica,

That is so true...No one will fight for you like you will!!!!  Everyone should fight for what they what and believe in.  Just like everyone knows that has had to fight for anything it is tiring, but don't give up...that is what the insurance companies are wishing for...they just want you to go away...

Thank you so much Monica for that great informtion!!!! 

Michele

Monica,

Thank you for posting this.  A lot of people will benefit from the wealth of information you have written.

Kim