Reaching out for Help with HealthNet in California
I know what I want...
*** gr/DS ***
I can't get my PCP's Medical Group to refer me to the Surgeon I want.
AND, I can't find a Bariatric Surgeon that does DS, AND takes my Insurance.
I'm in a pocket of the outer Bay Area (Livermore) that HealthNet doesn't know exists. (Well, at least it doesn't contract with any local Hospitals with GOOD Bariatric Surgeons. I'm willing to change Medical Groups/PCPs and even Insurers (if Kaiser has a decent DS Surgeon!)
Today I was able to connect with a woman at HealthNet who understood what I am trying to do and she showed me (on the website) how to find the policies re:Bariatric Surgery and come to find out, they only req 4 items, NONE of which is 6 months of playing the diet game. They DO cover DS but it's listed as BPD / DS, so my first question is could it be possible to just get the DS but with Gastric Reduction instead of BPD? or is BPD just a term for GR? Secondly, she said she was e-mailing me a list of Bariatric Surgeons, I could choose one, THEN find out what Medical Group he/she is in and switch to that group for my PCP. FINALLY, a solution was on the horizon,...then I waited for the email....and waited....and....well, the closing hour of the phone center was nearing so I called back (3x's) and finally got a person who confirmed it could take up to 24 hrs to receive the email, however, HER email was down. (the first 2x they told me, they weren't capable of emailing anyone). Anywho...Additionally, this 3rd person then tried to walk me through finding a Bariatric Surgeon on HealthNet's website, Can you believe there is no checkbox for Bariatric Surgery, only General Surgery...A quick scan of them told me I was heading back to square one when I thought MAYBE ObesityHelp could (help) so here I am....
Thanks in advance,
seeking....
First, BPD/DS = DS = GR/DS.
Second, find out if Health Net contracts with Rabkin (I can tell you the answer is no), Cirangle or Jossart (probably yes - I'd go with Jossart if you can), or Keshishian (in Delano, near Bakersfield - trust me, it's worth it).
If any of them contract with HN, you'll need to find out how to get access to them. Then you have another issue - with Cirangle, there is a HUGE (like $10K? you'll have to check) "program fee" - that insurance DOES NOT COVER and which has to be paid UPFRONT, in addition to whatever copay you will have. Jossart just set up his own practice after splitting from Cirangle - I don't know what his program fees are, but I'll bet he has them. Personally, I wouldn't go to either Jossart or Cirangle, because I don't like them - but that's just me.
Now let's say neither J or C are in-network. Now you have Keshishian, who is likely IN network, but you have to drive nearly 200 miles to see him in Delano. AND he has a $3K program fee. But HE is at least worth it, IMHO.
And you have Rabkin, in SF, but out-of-network (he contracts with almost NOBODY). Much more convenient, but more expensive - OR IS HE? Rabkin has NO program fee, but requires 2/3 of his surgeon's fee (currently $13-14K) upfront. Then he submits for insurance, and if your insurance pays more than the other 1/3, he refunds you the difference (if your insurance pays less than the 1/3. you owe him the difference). IF your insurance plan only pays crappy out-of-network benefits, you could be liable for most of his fee. HOWEVER, if there is NO in-network surgeon within 50 miles, HN may have to pay Rabkin at in-network rates (however, because he is in fact OUT of network, you will still owe him the difference between what HN pays and his full rate). AND Rabkin operates at at least one hospital that is in HN's network so the hospital fee (which is the biggest part of the cost, and the most subject to increasing astronomically with even a minor complication) will be covered in-network.
THESE ARE THE ONLY QUALIFIED DS SURGEONS IN NorCal (Keshishian is arguably accessible to NorCal). IF NONE OF THEM ARE ON THE LIST, YOU SHOULD BE ABLE TO ACCESS RABKIN BASED ON HIM BEING THE CLOSEST SURGEON QUALIFIED TO PERFORM YOUR SURGERY, AND THAT HE SHOULD BE PAID AT IN-NETWORK RATES.
OK, if THAT wasn't confusing enough - NorCal Kaiser has NO DS surgeons - HOWEVER, they have a contract with RABKIN! Yes, although Kaiser is a PITA about the DS, and refuses to acknowledge in its classes that it exists, or at least dismisses it as outmoded and way too dangerous, when the patient demands it, they almost always win, after either going through the agonizing appeals process (with which you will get free help from me and Larra), or - in some cases, especially if your BMI is >50, NorCal Kaiser will send you straight to Rabkin without needing to appeal (don't be too impressed - they know they are going to lose, and they figure they improve their own stats by dumping the fattest, oldest and sickest patients on Rabkin). And if you access Rabkin this way, Kaiser pays essentially 100% of the cost.
But that means waiting until open enrollment, changing plans, getting with a PCP, getting into the bariatric program and going through the appeals. And hoping the relationship with Rabkin remains the same between now and mid-next year.
Aren't you glad you asked??
http://www.paclap.com/video/index.cfm?filename=patients#vide oAnchor
my entire post wasn't showing, crud, now I think I lost it....
