Please help...I'm desperate!!!

Ok...I tend to pop in to OH when I'm desperate since my first response to any problem is to break my neck trying to solve it on my own. Then suddenly I think "what about OH? Surely someone there has had similar problems!" I hope this is one of those times!

My third attempt at getting surgery began a year ago last August. I saw an old friend at a festival, who told me that she was on Medicare and was able to get surgery. She looked incredible. So, with my hope tucked underneath my arm, I made an appointment with her surgeon and began the process once again. Well, although the office had all of my medical history, the office "gatekeeper" did not see that I listed "bipolar." Nor did the surgeon blink when I, again, told him I was bipolar during my initial checkup. After many months of hard work completing my weight management, loosing 20 lbs, getting my psych eval, etc, I was almost ready to go!! Then I got the phone call. I was told that the surgeon could not do my surgery. Why? Because I am bipolar! I became severely depressed and wrapped myself in hopelessness.

Next, I posted here, and someone wrote to me privately recommending her surgeon, who handled her case through Medicare despite her bipolarism. My spirits were up again, so I started out again with my silly little optimism beside me. I met with her doctor, who had requested the information from the previous surgeon's office on my weight loss management and my psych eval. I left after my initial visit feeling so happy and relieved. He said I would be able to get my surgery within a month or so!!!

Then I got the phone call (but this time I was still in the car traveling back home). I was told that I would have to completely redo my weight management because I only had six meetings and the guidelines stated that I must have seven to complete six months. Huh? Again, I was crushed.

So, I ask you good people, WTF? Both surgeons are in Houston, both surgeons take Medicare (Trailblazer), both say "we're good to go!", and both offices screw me. I wasn't giving up yet though. I made an appointment with my primary doctor, but she won't do a weight management with me because "it's not her job." I go to a previous doctor, who says the same thing. By this point, I'm three months into what could have been half of a new weight management program. And I'm ticked!

Thanks for reading my rant! I hope no one else has to deal with such bs from Medicare/Trailblazer and surgeon's staffs!

pfenix

Sorry I can't help, one question though.  Is the 6 month weight loss program a doctor requirement or a Medicare requirement?  

Well, that's actually a tricky question! The weight management is required by Medicare, except that Trailblazer (the management company for Medicare in Tx and surrounding states) sometimes adds its own stipulations. The problem is that neither Medicare nor Trailblazer states how many visits equates to six months, so various surgeon's offices make up their own guidelines and assert that it is what Medicare requires. Medicare, however, stipulates six months with three of those months being consecutive. So, in reality, if the second surgeon's office wanted seven visits, I should just be able to go for one month and be done.

I had the two surgeon's offices talking to each other about his discrepancy for a while. The end result is that now everyone says "its our requirement" rather than pinning it erroneously on Medicare. What it all boils down to is that Medicare does not preauthorize anything, so the surgeons are uptight and over-shoot rather than risk not being paid for a claim. This is coupled with Trailblazer being completely shielded from members; the only ones who can directly contact Trailblazer are the doctors!

And, of course, because the federal government is in the process of altering health care, I fear that I will no longer be able to get my surgery at all!

pfenix

Sorry...I have no weapons for you either. But I just wanted to add that I have Medicare and when I was getting approved for surgery last year, at that time, they only required a 3 month weight management period for me to go through. All that meant was I had to see a nutritionist for 3 months straight for documentation. So my surgeon had me visit with his NUT for 3 months. I know Medicare could have changed it's policy to make it 6 months, but seeing a Nutritionist may still be sufficient enough for the 6 months requirement.

Did you notice there's a thread, 2nd from the top, just for recommendations of Medicare and Medicaid surgeons?  You might want to try there if you already haven't.  You could PM some of the people that posted there to ask specific questions esp related to bipolarism.

Thanks for the help so far everyone. I did find the list of Medicare surgeons and plan to call some of them. As for the three months, I was told that Medicare specifies that I have to have three consecutive months of weight management but six months total. There is no specification for the exact number of visits.

pfenix

At last I can say I HAVE A SURGERY DATE!!!

I decided to go with a new surgeon (he is my fourth...haha), Dr Nowzaradan. He was confused when I told him my story to which he responded "let's get this done!" After several visits to complete my testing and order my paperwork from other surgeon's offices, I walked into the office last Thursday, 1/14. The nurse gave me some paperwork to fill out, the doc came in and asked if I had any questions about the surgery, and then I was sent to the office to get my surgery date...it is on Tuesday 1/19. My head was spinning!

I would like to thank all of you for your kind words of support. If anyone has any problems with this process, please contact me. Although I do not have all of the answers, I encountered enough problems to be a little wiser for it.

I am interested in fighting to make ALL information regarding Medicare/Trailblazer specific, clear, and available to anyone through the internet. At this point only health care providers can have access to Trailblazer even though it can have a dramatic impact on those of us on Medicare. If anyone has any ideas regarding how to approach this, I would love to hear you...I simply do not want anyone to have to go through what I did!

pfenix