OMG! Thank You and Yes, I’m very glad I asked.

 

I may just switch to Kaiser after what I read in your post.

I know Dr. K (was in Delano, now in LA), My ex-hubby and his wife and sister all had gr/DS with Him back in 2000-2001. I did the informational visit with him in 2003 but wasn’t yet convinced I couldn’t just hunker-down and get serious with Weigh****chers and knock off 200+lbs, lol.  8 years later with my weight having been relatively stable I realize that if I were down 200lbs. I’d also be maintaining my weight. So His office (note the Capital H when referring to “Him", this is for the God-Like status he holds in my mind) was the first place I called. They don’t contract with HealthNet. If I were a rich person, I would make the trek for I know He is worth every mile. However, my finances will not recover from this economic downturn anytime soon. I used to work in the Silicon Valley at a high-tech firm. I now work at a major Home Improvement Retailer for about 1/3 of my previous salary.

I also contacted Dr. Cirangle’s office (an acquaintance had him do a lap band a few years ago) his staff said they didn’t contract with HN either.

It seems like Kaiser might be the way to go, since my BMI and co-morbidities make me a candidate to be outsourced. At 341lbs my BMI is between 60.2 – 62.4 depending on how they assess my height. I’m technically 5’2.75" (according to Dr. K’s office) so some call me 5’ 2" and some say 5’3". Either way, I think I qualify(huh, qualifying, the word makes me think of a race or a contest. Did I win?  Lol)

My open enrollment is coming up in Nov for a Jan 1 start date.  Would I still need to do Dr. Rabkin’s upfront fee if Kaiser refers me.

One of my other thoughts was to change back to my previous PCP in San Joaquin County and hope for a referral to Dr. K. (my Medical Group was Sutter-Gould, but there is still the issue of no HN Contract.)

Thank You again for your post, it made my night!

S~

P.S. I don’t know why I thought that was you on the success story….sorry for any confusion. I went back this morning and am still scratching my head over it.

With Kaiser, there is no upfront fee at all - it is the best bargain in the DS world, once you get past the roadblocks they put up.  And you don't need to do their bariatric program - classes or dieting or any of it.

Susan, Diana is the best for explaining non-Kaiser insurance so I won't try to add to her explanation. I will advise you to get your insurer's policy regarding bariatric surgery IN WRITING, one way or another, and not to rely on what someone tells you on the phone. Keep in mind that YOU are the one who cares about the outcome of all this, not some insurance company employee.
     Also, keep copies of all correspondence and emails, and make a summary of every phone conversation, including name and job title of the person you speak with, date, time, and a summary of the conversation. You never know what you might need in the future.
     What I suspect will eventually happen is that you will be approved for "wls" and your plan will say that it covers the DS, but there will be no in-network surgeon who does the DS so they will insist that you see some in-network surgeon who doesn't do the DS. It's sort of a catch-22. We've seen this many times, and it's definitely something you can fight and win. You will need to do the stuff Diana described to force them to pay for someone out of network. But the first step is to figure out what you need to do to be approved for wls, do that, and THEN worry about which procedure.

Larra

Thank you Larra,

I finally got the email from Sue at HealthNet (the list of Bariatric Doctors) I recognize some of the names as Doctors who are listed on this website, but not sure yet if they (seriously) perform DS.

I was re-reading HealthNet's policies re: WLS and noticed that Dr. Rabkin's name is quoted in one of the studies that was used to make a point on a part of their reasoning for pay/not paying for a particular procedure.

I'm going to try again to repost what got lost last night as it has a little of my background in the WLS side of my life.

I'm not very good at record keeping but your post made me see how it could be to my advantage in the long run. One good reason for the networking that goes on here is to learn from those of you who have gone before us. I can't clearly express just how much I appreciate having access to You Veterans. You are invaluable to me. Thank You again.

S~

Good record keeping isn't just to your advantage, it may prove essential. Even if you don't do it in every aspect of your life, make this a priority. There is no telling at this point how much of a fight is ahead of you, or exactly what shape that fight may take.
     If the surgeons you see listed are in CA and have names other than Rabkin, Keshishian, Jossart,  Cirangle or Crookes, they don't do the DS. It's that simple.

Larra

Thank You Larra,

I didn't see any of them on that list. So, I've pretty much abandoned the idea of going through HealthNet. My open enrollment is coming up, I will switch to Kaiser and go from there.

Thanks again for all the help,
I appreciate it.
Sue

But you can FORCE them to pay for a qualified DS surgeon, if they don't have one under contract.  Just so you know.

Since I hate HN with a purple passion, I'd like to see them on the hook for your DS.  On the other hand, you can have Kaiser in 3.5 months, and you probably can't get through the appeals with HN in time to force them to pay for it.

I still think you should get a self-pay consult NOW, e.g., with Rabkin, and use it both start a claim with HN, and then use it for your request with Kaiser, and then see if you can get Kaiser to force HN to reimburse them for the surgery Kaiser ultimately has to pay for.  That has a certain sense of fair play to it, don't you think?

Uhm, I don't think I have that kind of fight in me...What's the point of paying out of pocket costs to Rabkin now?  I don't see the fair play in what you're suggesting but I'm opening to hearing more about it.

I would think Kaiser might be less inclined to pay at all, if they know I've switched to them JUST to get the DS.

It's been a LONG day and it's my Monday, so I'm gonna call it a night.
But I will be thinking about this over the next few days.

OH, and I will be at the meeting on Wednesday...

Thank You again for all the input, it's great!
S~

Not so fast!
      If your DS is covered by HealthNet, they can't deny you just because the surgeons who do it aren't in-network. Well, they can, but you can force them to pay for what is in the contract with an out of network surgeon. They can't say they cover something, then say they won't cover it just because it can't be done in-network. Your policy is a contract.
     If you do switch to Kaiser, be advised that you will need to start the whole process from step 1, and that you will get a denial from the Kaiser surgeon, guaranteed. You would then need to file a grievance to start the appeals process. You can win this process, but what I'm saying is that either way, you are going to go through appeals to get a DS. You can succeed, and get your DS, just be aware that no one is going to hand it to you.
      And hey, come to the meeting next Wednesday. We love meeting people from OH in person.

Larra

Not so fast?? lol I can't make the actual change until some time in Nov.

Nothing is moving forward at this point. I've been "denied" by my Medical Group. (A technicality I'm sure because I haven't 'completed' the 6 month Nutritionist Counseling, having started that in August, it will take me until January to finish OR change PCPs, then "start over again") Not sure HealthNet even knows (officially) that I'm wanting WLS. Well, maybe now that I've requested a list of Bariatric Surgeons they might. So, "starting the whole process from step 1" isn't really an issue for me at this time. I expect I could start over a few times before all is said and done.

In my mind, this is a complicated procedure (Insurance Approval) and I realize that things could change at every step. I'm open to doing what it takes to get the surgery I want. When I first started this process, I wasn't sure DS was the ONLY option for me and until it comes down to the wire, I will not be CERTAIN that Kaiser is where I'll end up. I've even thought of transferring (in my job at work) to another state to get what I want. But I'm pretty certain that NorthernCali is the best place to get this surgery (slightly prejudiced here as I'm a Native to the Bay Area).

I'll bring all my paperwork to the meeting, including my notes on conversations with Hills, Drs, HN, etc.

Time to get to work...
S~