urggg!!!! I need ins advice

I am on AHCCCS (ap/ipa).I spoke with a caseworker the other day and she asked me some questions, because my dr is trying to get me authorization to go to my one on one and get scoped.She flat out told me that I did not qualify.But my bmi is 51.7 and i have a bunch of health problems.Who r these pencil pushing geeks that make up this criteria.They make it so impossible for anyone to meet the "criteria" that they have set for people.I think they want you knocking on deaths door, with no chance of ever having a normal life.they also seem to think that people that are on public assistance are drug addicts and lazy people.I am not lazy or a drug addict.She also had the nerve to ask me that.I was shocked.I have no choice but not to work right now.I worked every since I was 16.My son is disabled so I take care of him.I just dont like the things she was implying.So anyone with ins advice I would sure appreciate it.Thank you.

Tanya, I have worked with many insurances and there is no bending of rules! Period! You have to meet certain criteria, and much of it is time related so...the sooner you get started the sooner you can post all your happy losing details to us! Two weight loss attempts. One at least 3 consecutive months and one six consecutive months WITH documentation from your doctor monthly. Weigh****chers records or similar does NOT count. Psych eval. At least 2 co-morbidities. BMI over 40. Cardiac clearance....etc. Some rules may vary and I know you need pre-auth to take each step in this process which is very time consuming in iteself BUT it can be done. Many patients work through the steps to get their health back! You sound motivated and intelligent so just give up on fighting the system and DO IT!!!!! Your requirements may vary so I'd find out the EXACT requirements to the "T" before embarking. Keep copies of everything yourself so no one can claim they lost your stuff and meet each and every deadline. Documentation is a MUST!!! Go for it! You can do it! Joyce

Thank you Joyce I guess I just needed the encouragment.I am working on getting everything documented.I am a little put out with my primary care physician too.I have been trying for his office and him to get the paper work done for 2 years.I could of had most of the requirements met by now and probably had the surgery by now.He told me he will do the referal and then it is up to me to do the rest.I told him that is not how it works with my insurance.And the kicker is he suggested the wls to me in the first place over 2 years ago.Go figure.But thank you for the response, and I will not give up.I will keep posting on my progress, and when I am on the loosing side we can all celebrate together.Because I am that determined to begin my life again.Thanks you.

Tanya, Unfortunately, most people making these decisions are pencil pushing geeks needing a power trip. You don't qualify? Ask for the SPECIFIC WAYS "they" feel you do not qualify. Use words like SPECIFIC QUANTITAVE and QUALITATIVE REASONS they deem you are unqualified. Specifically who made the decision and what are their qualifications to make that judgement? Joyce gave you absolute tenets to follow and you will have to fight. Being on AHCCCS does NOT automatically categorize you as a drug addict or lazy ....NOBODY has a right to treat you as such. You CAN beat the system by scrupulously following their rules, knowing their rules and requirements and being a couple steps ahead. I know, I forced a MAJOR HMO at a national level to pay for a loved one's heart-double lung transplant. It took tons of work, research,documentation and timing but by God's grace it happened. Know that AHCCCS stands for AZ Healthcare COST CONTAINMENT SYSTEM - this means they don't want pay unless necessary. Make sure you get copies of the PC's records documenting his recommend for WLS ....and other records from other docs that support your need for this surgery. Letters of medical necessity from all your docs builds a case for you. Document EVERY phone or personal contact with AHCCCS on a calendar - who you talked to,their title.date and time of contact and a summary of what was discussed/happened. Be polite but business-like in your conduct and don't volunteer information unless necessary. Phone conversations ARE RECORDED and probably face to face interviews also. Request information and or explanations verbally first then in writing by certified mail giving a time frame they need to reply in(example- 5 business days).This shows the insurance company you are serious. Ignored requests for information do not reflect well on the Insurance company and can be used against them. AHCCCS wants you to give up and go away - most people do. Persistance is key... even when all isn't going well. Start with finding out what the criteria is and obtain it in writing from AHCCCS. Then start putting your "case" together. Hopefully meeting all the criteria will get you there quickly and smoothly, but cross those "t's" and dot the "i's" all the same! Fight the good fight and know there are lots of folks here to offer you support along the way! Kathy

Hi Kathy! Thank you so much for all your advice and comments.I really do appreciate everyone's input on everything.I am trying to do everyting I have to by the book.So we will see what happens.Believe me I am a very persistant person.I do not care if they tell me to go away.I don't listen very well, especially when it is something I really want or need.LOL.My mom tells me sometimes I am too pushy.But I have to remind her I usually get what I want or need.But thank you for all the kind words and support.This website is so awesome.Thank you again Kathy and sorry it took me so long to respond. Tanya

Tanya, I also am on ACCHSS, but I have Mercy Care and got approval on the first try. I just got my refferal letter to the surgeon on Friday, and will be calling to make my appt. on Monday. Maybe you could just change the plan you are on. I hope this helps, and good luck. Sarah