Ga Medicaid/WellCare Issues...Help PLZ!

I live in Waycross, Ga. Back in February I was dx w/ CHF. My PCP advised me to get some type of Bariatric surgery. I'm 363# @ 5'6" and 40 yrs old. Back in May I called WellCare and asked them if they would pay for this type of surgery and they told me 3 different times that as long as the dr. showed that it was a neccessity that they would. Well the only dr. she knew of in S.E. Ga. that accepts/accepted Medicaid per say is Dr. Henderson. So my PCP "referred" me to him. He is about 1 hour away from me. I had my first visit and was told that since Medicaid had went to these HMO types of plans that he had stopped taking it, but considering the health issues that was going on with me that he would do the "sleeve" on me. I didn't get an option, just the sleeve. I was also told I would need to go ahead and pay the $1,200.00 for "program fees" and go ahead with the nutritional, pychological and weekend siminar. I didn't have the money and my son that is in the Army sent me the money to get it all done with. Everything was completed within a few days. All of this was submitted to WellCare, and they denied me. Saying that Dr. Henderson was not in their "network". But I had been "referred" by my PCP. One of the ladies in the office called them and told them that I had been referred to him because there are no other surgeons in S.E. Ga. that would accept the insurance for this type of procedure.They told her that they would send a list of things that I needed to complete before they could make a decision. On this list it said, "a 6 month doctor followed diet" among other things. I went to my PCP and me and her got together on this and figured out how we were to go about getting all these things done in a timely manner. About 2 weeks later they sent ME a letter that said, "a 12 month doctor followed diet". And that they needed to speak to my doctor within 3 days of me recieving this letter. So when my PCP called WellCare to find out which they needed a 6 mo. or a 12 mo. followed diet, they said they would not talk to her about me, because she is a Nurse Practioner. I called them and tried to tell them that she's been my doctor for over 10 years and no one knows me like she does. They pay her to see me and order anything that needs to be done on me so why wouldn't they speak to her about me!! They would not speak to ME about ME!!! They said it was a HIPPA thing. I told them that I'm a nurse and that YES you can talk to ME about ME!!! But they refused!!! Can you believe that?! Anyway, my question is has anyone ever heard of such before??? I knew going into this that it would be hard to get them to pay for this but still, there are people that I know that have this type of insurance and have had it done, so I know it maybe hard but not impossible. I can't start over with a new doctor! My PCP says that she works under another REAL doctor and that she didn't appreciate them be-littling her like that, that she's going to write an appeal and have her boss to co-sign it with her to try to get these fools to talk to her about me. They said in this letter that they have "in-network" doctors. But they sent me this book that only has gastrointestinal doctors not bariatric surgeons!! I just don't know where they are coming from and what in the world they want!! I need some advise, any kind from anybody.......I've already invested the $1,200.00 in this particular doctor and I think he would do a good job (although the only option with him is the sleeve). My son is at wits end, he doesn't have any more money to send me for another surgeons "program fees", and I don't want to lose his money. Can anybody out there help me???????????

I am sorry you are going through this... however, I would suggests reading the above post... link is here: http://www.obesityhelp.com/forums/GA/a,messageboard/action,r eplies/board_id,4812/cat_id,4412/topic_id,3461362/

i'm glad you replyed to my message. And yes, I went to where you instructed me and read. Although everyone there was talking about Medicare. Yes, I did see one that was talking about medicaid per say but that was at least 5 hours away from me. That one lady "Phylis" I think was her name was works for Dr. Kent in Brunswick which is also in the same office as Dr. Henderson the Dr. that I am trying to use. She states that they don't accept medicaid. But when I called and was able to talk with Dr. Henderson and told him of my co-morbitities(?) he said that he would accept the WellCare this one time due to the cir****tances. But WellCare themselves is giving me a fit because my PCP is a Nurse Practitioner not a DOCTOR. Thx again for your time, Deb

I'd suggest you document everything thoroughly.  You have a battle in front of you.  Make sure you write down who you talk to at your insurance company.  You just might have to meet with the doctor the nurse practitioner works for.  You just might have to have that person call your insurance company.  Fighting with them probably won't get your surgery paid for.  Ask them for approved Medicare providers.  I know there are some in Atlanta and there are probably some in other areas.  As close as this one?  Probably not but... if you want them to pay, you have to jump through their hoops.

This problem didn't happen overnight.  If you have to follow a doctor supervised diet for 6 months or a year, I'd suggest you get an actual M.D. to treat you and get involved.  You can always see the nurse practitioner you like but if your insurance company disqualifies any of these people because they aren't an M.D. or in network, you are wasting your time and money.

If your doctor refers you to a surgeon and not the insurance company, that isn't the same thing.  You need your insurance company to provide you a list of approved surgeons they work with.  Otherwise, you're fighting a losing battle.  Someone saying they'll "take it this one time" isn't the same thing as your insurance company telling you who to go to.  Write it all down.  Document dates, names, etc.  I have Blue Cross and had to do the same thing.  it is what it is.  Trying to make their square peg fit in your round hole isn't going to make it happen.

Good luck on your journey.  Sorry about the $1,200 hassle.  That may not be the best outcome but the tests you had done can be sent to another surgeon's office so it's not compeltely lost.

Thx Mick for the advise.
Since I've posted this I have talked again to the surgeon's office and told them about WellCare not speaking to me or my PCP. The lady that deals with the insurance companies said to ignore that letter that I recieved and to get my PCP busy on trying to get all the testing done and the paperwork together and fax all of the above to her and she would deal with them. She told me that I haven't been denied yet but from what she had told me before I had been. When I reminded her of this,she said that she had tryed to submit via the net to the insurance company and because they are out of network they denied the claim.
OK I didn't understand but OK if she wants to deal with them then so be it, it'll take some of the load off me.
I went to my PCP last week and she said that she had just found out that another one of her patients was just approved after only trying 1 time and she's 400# and has no co-morbs. Her insurance is through the other HMO company that Medicaid has now AmeriGroup.
As far as a list of surgeons they have none listed. The book that they sent me with a list of doctors in the state of Ga. were all gastrointestinal not bariatric. So when I talked to the surgeon's office in Brunswick I told her this and she said that for me not to worry so much and let her handle it.
So I'm taking it all 1day at a time. If it's just a no go and no matter what, after I've done all this and that and they still say no, then I'm taking money out of my workers comp settlement and going to Dr. Alverez in Mexico. I have no other alternative, I've got to get this surgery.
Although I don't know when I'll get my settlement, they wanted to settle last week and I told them I wanted a 2nd opinion. So now I'm off to see a different doctor and maybe get more of a settlement then I would have, hopefully. But regardless I'm still going to try to get medicaid to pay while I'm waiting on this other so....just trying anything I can to get this done....Thx again for all your help, it's appreciated very much.......Deb

I went round and round with Wellcare, and to no avail, I couldnt even find Dr Henderson that you speak of, I guess Im lucky now that I have read your posting!  Wellcare even pulled the rug out from under me a few times.  Dr Williams was taking me with straight medicaid at one point wayyy back and then I got pregnant and had a different plan he didnt accept, i had to wait to get on Wellcare and chose this plan because they too, told me they would pay for the GB surgery. Nope, no such luck.....total chaos....finally, I have married again and I have his insurance so I am not stressing so much.

The best advise I can give is to NOT GIVE UP!  and to get yourself a journal and keep track of who you call and what they say and when......and dont stop calling.

Maybe try calling your local social service office that handles your case and find out when and if you can change your plan.....I know peachcare will do it (the surgery) and i have heard that doctors in our area DO accept it......

Keep me posted, take care
pam

Dr. Henderson is in Brunswick. He and Dr. Kent both do these types of surgeries among others. Their practice is called Georgia Coast Surgical.

I'm probably going to just go to Mexico. I mean I'm trying to get them to pay but if all else fails I'm going there. Right now I'm trying to get over a summer cold so I can go take those dern tests!

Thx for replying. I'll have to add you to my friends list so we can keep in touch