What would you do?

Once again I made very little progress on the insurance front. My HR VP and Director spoke with the Carefirst Account Manager and he is now reviewing my case. No answer still even though I keep getting told I will know tomorrow and tomorrow and tomorrow. This time I don't even get a tomorrow. They can't give me any timeframe. The director said they don't think he will approve my surgeon of choice unless my PCP says he is the only surgeon that can do the procedure.... which we know is not true since other surgeons that can do it are in network. I asked her if I switched to the Mercy BC/BS triple option plan during open enrollment in July (same my co-worker also got approval on and 100% coverage) would I be guaranteed approval. Of course she couldn't tell me this. I asked her to keep that question in mind if the decision from the Carefirst rep is a no on Dr. Schweitzer. I'm really concerned though. If they say no I'm not sure what to do. Do I take a chance and put this off until July or do I just switch to another surgeon now? I have put off dealing with multiple health issues because I think WLS will resolve them so waiting that long I will have to deal with them - going on BP medication, seeing an endocrinologist to address the possibility of PCOS, going to an orthopedic to deal with my left knee pain. Is Schweitzer really worth waiting for in my scenario? All sorts of questions I need to think about. This choice for me has been even more difficult then having the WLS!!! Right now I guess I just wait and wait and wait until I hear from this account rep or set some sort of timeframe to come to my own decision if they take a long time. Again, they can't give me any time frame for a decision which to me is worse then a no or a yes. My healthcare remains on hold for now ... very frustrating. Got any thoughts or suggestions? Do you think I should start over and try to find another surgeon so I can get the procedure earlier and hopefully start to work on resolving some of these other health issues or stick with the one that is considered the best in the area? How long would you wait in a situation like this? Thanks for any advice!

Stacy, I think you need to look at what your priorities are. Is getting the surgery the most urgent thing for you? Then I would switch surgeons. If getting your health issues under control and you don't mind waiting then stay the course. However, it seems that sometimes we have to play the insurance game. Is it worth the stress, anxiety and hassle to try to force them into something they most likely aren't going to do anyway? Think about it. Insurance companies have their own agenda. Period. They aren't going to give in or change for one person just because you have different preferences. My advice would be to switch surgeons. But, that is what I would do. You should sit down and make out a list of pro's and con's then weigh that. It's sad, they literally have us "by the balls" if you will. Until we do something to change the way insurance comapnies operate, we will always be controlled by them. The even sadder issue is the people making these decisions have little or no medical education or background. At any rate, take a step back. Look at the whole picture and not just the bits and pieces here and there. What is it all worth to you? You may be fighting a giant that you know you can't beat. Good luck. Val

The onlt thing I would add the the great thoughts given here by all is: Make sure you get the best surgeon you can, make sure they have done many. Every problem I have read about with WLS was caused by technique, or lack of skill/experience by the surgeon. This is not to say the best surgeon in the worls will not accidently knick your bowel, but it is less likely to happen. I hope you get the outcome you need here, it is frustrating doing the circus tricks for the insurance. I felt like JOJO the the monkey boy, come on Jojo jump thru the hoop, now ride the bike. Look at Jojo is'nt he funny.

Thanks for the suggestions. I'm convinced Schweitzer is the best surgeon in our area for so many reasons. That is why this is such a hard decision. He was the first to do the Lap procedure in our area and is an acitve participant in the legislation action committee for my state. When people you work with in an OR that you respect tell you he is the best it is hard to ignore that too. I've seen the results with his patients. My own hospital was even trying to recruit him. I've been thinking about this all morning and did a pro's and con's list. If I don't hear anything in the next week I will call and follow up again with HR. If they still don't have a response for me I will start investigating a new surgeon. He may not be as good as Schweitzer but maybe I can find a compromise. Sad that I can't have the best but that is the reality of insurance and I know it all to well. My mother was diagnosed with cancer and wanted to go to Even that won't promise me an approval but at least I might have a better chance. It will fit better with my work obligations as well as my health needs. Starting over stinks but I've come too far and I am really concerned about waiting. Thanks again for the advice.

opps.. somehow I botched that response.. was adding in that my mother was diagnosed with Cancer and wanted to go to a top hospital by her in NYC - Sloan-Kettering Cancer Center. However, she had to settle for another place that was in plan and not her top choice. She didn't have the ability to waste time to fight the insurance. In the end she is now cancer free and doing very well.