kaiser denied appeal

kaiser denied my appeal so i filed a grievance with the dhmc. i hope they approve it. I,ve been on this journey since 2004. I got to the weight they wanted me to be at but never gave me an appt. so i put more weight on. Now they give me another goal weight after they dropped ball. Really wish kaiser was as easy going as some other health care providers.

What was the basis for their denial? I found Kaiser to be pretty easy going - i had to do a 3 mo program, and they asked us to lose 10% of our body weight, even though I know many people who gained weight and were allowed to have surgery...this was Southern CA area. 

The basis was because i had my appendix removed and said i had to wait 6 months for healing. I waited 8 months and nothing never returned my calls or anything. i was mad but i got over it what could i do.

The first thing I did was go to my ins companys web site and downloaded their rules regarding the different types of bariatric surgery and what it takes to qualify. I read that document from front page to last page 4-5 times and reviewed highlights and tabs before every call to the ins. company. My first call, before I called a surgeon, before I called the hospital, nut or psych was to the ins company and spoke with them about my intentions and asked them to open a case and review my conditions. They had no problem at all doing it. Second call was to COE hospital they recommended and signed up for their bariatric program. At that point I asked the ins company for a surgeon recommendation, went back to the hospital and spoke with them about the surgeon (bariatric surgeon of the year, glowing reviews, then when I was admitted every nurse I spoke with who saw the surgeons name, made unrequested reviews and every one was glowing. but he's not on DSFACTS, but thats another soap box).  I don't know what your record keeping entails but I went into every conversation with a goal and an action item. I made it clear what the action item was, whose responsibility it was and if there was an associated time line. I informed them to record their calls because I was recording mine. I got names and phone numbers, employee numbers of who I spoke with. I was always polite and never raised my voice, always asked for what they thought, what their opinion was.

I always had a full record of who I spoke with last, what we discussed and dates and times I completed what ever task they wanted me to do. I always wanted to know what was going to be required 2-3 steps out, what's next and what's after that. If they didn't know I escalated it. I called my ins. company every 2-3 days and I had a positive endgame answer inside of 3-4 weeks.

I recommend using One note on your computer and then using dropbox with that. I loaded dropbox on my work computer, my smart phone, my home computer, my wifes computer (she has been tremendously helpful in researching everything I've asked her with and a whole bunch of stuff on her own) we were able to add notes to one note from anywhere, then save it to drop box and drop box updated every other computer/phone or whatever any location.

Thanks for the info. i try to keep good records but  im always in a hurry.

You can get approved Joey, if you really want too. Are you sure this is what you want to do?

1) as long as you meet the insurance companies requirements for the surgery, that's the first thing to determine. 2) what do you need to accomplish so you do meet the insurance companies requirements? After that you are asking them to lay out tens of thousands of dollars on your behalf. You need to prove to them your serious about that and you're going in prepared. when they know you know what you're doing and you have a plan, they'll take you more seriously.

If you are going to take the time to call a doctor or ins agent on your case, this needs to be important enough to you that you keep good records and track of what youre doing. you have to set and keep appointments. if your job keeps you from this maybe theres other times during the year when its slower that you can get everything done. If you know that your ins company requires an appt with a NUT, psych and a cardiologist then don't wait on anyone to refer you, you can pick up the phone and set those appts. If your ins requires a doctor supervised weight loss program and you haven't done that, get hot man, theres a lot of programs out there. 1) your nut probably has one, 2) your PCP probably has one, Your local hospital probably has one Weigh****chers counts, medifast counts, ask your ins company to refer one and tell them why and you know that has to count.

You can do it but you got to want it because if you think the three months leading up to the surgery are a commitment, after surgery its a requirement with consequences if theres no commitment.

If you want some help with this I'll help you do it, but your going to have to commit to the process and do what you say you'll do when you say you'll do it.

Hey bigjoey1,

I agree with texasrigdiver. If you want this to happen then you really need to do something for it. All the paperwork, all the phone calls, all the questions you should ask and stay in touch with insurance at least once a week.

I can't help but think that you seem very nonchalant about the whole procedure and idea and that you just think it is too much of an effort to take care of all the stuff you need to do.

Think about the recommendations the insurance made, like have you singed up for psych eval and nutrition appointments as well as medical check ups. Are you going to meetings that you need to attend and so forth?

But, maybe it is not for you, cause it sure is easier to give up and do nothing and sit around and see you life pass before your eyes instead of really working hard for your goal to a longer and healthier life. YES, I am being sarcastic!

Good luck.

Hugs,

Rita

My Kaiser experience was a breeze I lost the 10% and then some I had to wait 4mos for a surgery date but I got everything done in 9mos. And here I am 60lbs later from surgery

Was your surgery in northern or Southern California Kaiser?

I did everything kaiser asked of me. I'm dieting and exercising and on track to losing the10%. I just hope they dont drop the ball. i just dont keep records of calls and conversations. I struggle every day trying to drop the weight  but im dong it slowly.