Southern CA Kaiser Approval for DS ? What Surgeon?
I have a friend who wants to get the DS
I know some people have had Kaiser approve for DS
Can anyone answer a few questions
My friend is already in the Kaiser WLS class and has done the class/ pre diet thing
I understand he will have to submit (through his PCP) a request for the DS
Then I assume it will be denied and he will have to appeal
Is this correct so far?
My question is what SURGEON for Southern CA folks did people with Kaiser insurance get?
How does that work?
I have read some got DS through Kaiser with Dr. Rabkin
What is the Recent results
Has anyone got DS with Dr. K paid for by Kaiser
Our plan is to consult with Dr. K and get a Prescription if you will saying he needs it or is qualified for it and then use that in the appeals process with Kaiser
I am just looking for any direction or guidance on this
Esp with who do kaiser pts get sent to IF they get their DS approved
Or does the patient get to pick who they want?
I also want to know what the Current coverage is for WLS for Kaiser southern CA
Thanks for any help or any place I can be directed for more info
He has all the comorbidities and would be approved for RNY .. but he wants the DS
(he has high blood pressure, type 2 diabetes, the skin issues, peripheral vascular disease, sleep apnea etc)
thanks for any tips
This is the latest that I know about SoCal Kaiser - Larra and I help people get insurance approval, especially with Kaiser, and it's a crap shoot - they keep changing the rules.
First of all, nobody whose insurance is regulated by the CA Dept. of Insurance/DMHC has to do a pre-op diet in CA - if you file a grievance with them, the DoI/DMHC will order the insurer to waive the wildly inappropriate and medically unsupportable requirement.
Second, NorCal and SoCal Kaisers are pretty independent of one another, especially their bariatric programs. NorCal contracts with Rabkin to do their patients who demand the DS and get approval from the DMHC. In fact, NorCal is sending their fattest and sickest patients to Rabkin now without them having to ask for it or appeal.
SoCal now has an in-house DS surgeon, Dr. Belzberg, who has limited experience with the DS, but did train with a vetted surgeon (I can't remember who at the moment - perhaps Anthone). The last couple of SoCal Kaiser people whom Larra and I have helped get approval for the DS were sent to him, after consulting with Keshishian and/or Crookes.
Now, here is the problem. Your friend will need a consult with a real DS surgeon in order to get a letter of medical necessity (LOMN) saying the DS would be better for them than an RNY, Lapband or VSG. I do not believe Belzberg would ever recommend a DS - he's a Kaiser surgeon and he toes the line. So if your friend asks for a DS now, I think Kaiser is going to send him to Belzberg, rather than deny the referral (because in the previous cases, Belzberg was not acknowledged INSIDE Kaiser to be a DS surgeon). But now that he's done a couple of them, Kaiser can send people to him, rather than deny - thus giving you nothing to appeal, at least not at first.
So, he may get sent to Belzberg, who is going to say No, you aren't a good candidate for the DS. Now you have on the record a DS surgeon (yeah, whatever) giving his qualified medical opinion that you are not a candidate for the DS. So then what? You're going to have to go outside of Kaiser to get a second opinion.
Now here's the thing - DS surgeons tend to charge a fee of about $300-400 for a consult and submission of paperwork, including writing the LOMN. This is essentially a "loss leader" because it costs them WAY more than that in time and effort - they figure they'll recoup some of the time on the surgical fees. But the SoCal DS surgeons now know that Kaiser has an in-house surgeon, if they lose appeals. So what are Keshishian and Crookes supposed to do when they get a SoCal Kaiser patient asking for a consult? Should they charge their usual "loss leader" fees, knowing full well they will never be this patient's surgeon?
I don't know how this is going to play out over the next few months.
First of all, nobody whose insurance is regulated by the CA Dept. of Insurance/DMHC has to do a pre-op diet in CA - if you file a grievance with them, the DoI/DMHC will order the insurer to waive the wildly inappropriate and medically unsupportable requirement.
Second, NorCal and SoCal Kaisers are pretty independent of one another, especially their bariatric programs. NorCal contracts with Rabkin to do their patients who demand the DS and get approval from the DMHC. In fact, NorCal is sending their fattest and sickest patients to Rabkin now without them having to ask for it or appeal.
SoCal now has an in-house DS surgeon, Dr. Belzberg, who has limited experience with the DS, but did train with a vetted surgeon (I can't remember who at the moment - perhaps Anthone). The last couple of SoCal Kaiser people whom Larra and I have helped get approval for the DS were sent to him, after consulting with Keshishian and/or Crookes.
Now, here is the problem. Your friend will need a consult with a real DS surgeon in order to get a letter of medical necessity (LOMN) saying the DS would be better for them than an RNY, Lapband or VSG. I do not believe Belzberg would ever recommend a DS - he's a Kaiser surgeon and he toes the line. So if your friend asks for a DS now, I think Kaiser is going to send him to Belzberg, rather than deny the referral (because in the previous cases, Belzberg was not acknowledged INSIDE Kaiser to be a DS surgeon). But now that he's done a couple of them, Kaiser can send people to him, rather than deny - thus giving you nothing to appeal, at least not at first.
So, he may get sent to Belzberg, who is going to say No, you aren't a good candidate for the DS. Now you have on the record a DS surgeon (yeah, whatever) giving his qualified medical opinion that you are not a candidate for the DS. So then what? You're going to have to go outside of Kaiser to get a second opinion.
Now here's the thing - DS surgeons tend to charge a fee of about $300-400 for a consult and submission of paperwork, including writing the LOMN. This is essentially a "loss leader" because it costs them WAY more than that in time and effort - they figure they'll recoup some of the time on the surgical fees. But the SoCal DS surgeons now know that Kaiser has an in-house surgeon, if they lose appeals. So what are Keshishian and Crookes supposed to do when they get a SoCal Kaiser patient asking for a consult? Should they charge their usual "loss leader" fees, knowing full well they will never be this patient's surgeon?
I don't know how this is going to play out over the next few months.
Okay so here's the scoop as I understand it:
First, you don't go to your PCP to request the DS. That's done through the Bariatric Program. You simply tell them you want a DS. They will send you to Belzberg who will tell you all the reasons he disapproves of the DS. Good luck on convincing him.
Now here's the part I'm unclear on. I got my DS. I didn't have a letter from an outside surgeon. I DID however go to Crookes' Information Meeting and I talked to him personally. He said he'd do my surgery.
That DID come up in my consult with Belzberg which may or may not have anything to do with him going ahead with my surgery. Make sense?
As an aside, he did an excellent job, gave me a "pretty" belly, and I've healed super nicely.
I have no complaints about him as a DS surgeon. He's exceptionally good at his job.
He doesn't particularly care for WLS in general. He doesn't like the DS at all. And if you don't know your stuff preop he'll chew you up and spit you out. So be prepared to go toe to toe with him. I got exceptional care from him once we got past the "I'm getting my DS" "No you're not" "Yes I am" stage. He said I was a know it all. I said I respected him as a surgeon but I intended to get my DS. We came to an understanding. And I know it doesn't sound like it, but I like him. He's a great guy, and an amazing surgeon. I was lucky to have him.
First, you don't go to your PCP to request the DS. That's done through the Bariatric Program. You simply tell them you want a DS. They will send you to Belzberg who will tell you all the reasons he disapproves of the DS. Good luck on convincing him.
Now here's the part I'm unclear on. I got my DS. I didn't have a letter from an outside surgeon. I DID however go to Crookes' Information Meeting and I talked to him personally. He said he'd do my surgery.
That DID come up in my consult with Belzberg which may or may not have anything to do with him going ahead with my surgery. Make sense?
As an aside, he did an excellent job, gave me a "pretty" belly, and I've healed super nicely.
I have no complaints about him as a DS surgeon. He's exceptionally good at his job.
He doesn't particularly care for WLS in general. He doesn't like the DS at all. And if you don't know your stuff preop he'll chew you up and spit you out. So be prepared to go toe to toe with him. I got exceptional care from him once we got past the "I'm getting my DS" "No you're not" "Yes I am" stage. He said I was a know it all. I said I respected him as a surgeon but I intended to get my DS. We came to an understanding. And I know it doesn't sound like it, but I like him. He's a great guy, and an amazing surgeon. I was lucky to have him.
"Mediocrity knows nothing higher than itself, but talent instantly recognizes genius." Sir Arthur Conan Doyle
"What your heart thinks is great, is great. The soul's emphasis is always right." Ralph Waldo Emerson
"What your heart thinks is great, is great. The soul's emphasis is always right." Ralph Waldo Emerson
Diana,
Do you know where the line is between SO Cal Kaiser and NOR CA Kaiser is geographically
What about Central CA, in the Arroyo Grande, Pismo Beach, San Louis Obispo area?
We would like him to go to Dr. Rabkin instead of Belzberg
Just wondering what exact cities fall under which region .. is there a map LOL
Do you know where the line is between SO Cal Kaiser and NOR CA Kaiser is geographically
What about Central CA, in the Arroyo Grande, Pismo Beach, San Louis Obispo area?
We would like him to go to Dr. Rabkin instead of Belzberg
Just wondering what exact cities fall under which region .. is there a map LOL
Loretta, I think if he calls Kaiser and asks what areas are covered, he can get the answer to that one. And there might be some areas of CA that are not covered under either NorCal or SoCal Kaiser, I'm not sure, so it would really pay for him to double check with Kaiser before making any moves.
I agree with Bookfaerie that the pcp will be no help at all - it's the bariatric program that makes all the decisions after the initial referral, and he's already past that point. I think what he needs to do (and I'm sorry you're getting different advice from different people, but this just goes to show how confusing SoCal Kaiser's program can be) is make a specific request for Dr. Belzberg at Kaiser in Harbor City, and when he gets there, make his case for the DS. And as already pointed out, he needs to really know his stuff.
If he has already completed the Options classes, there is no point in filing a grievance over it. And if they demand pre-op weight loss that he hasn't done yet, that can, as Diana said, be successfully appealed. But if he can get to Dr. Belzberg and make a good case, he can get a DS.
If he does move to the NorCal region, he will probably need to start the approval process over again, as this is a separate insurance program.
Larra
I agree with Bookfaerie that the pcp will be no help at all - it's the bariatric program that makes all the decisions after the initial referral, and he's already past that point. I think what he needs to do (and I'm sorry you're getting different advice from different people, but this just goes to show how confusing SoCal Kaiser's program can be) is make a specific request for Dr. Belzberg at Kaiser in Harbor City, and when he gets there, make his case for the DS. And as already pointed out, he needs to really know his stuff.
If he has already completed the Options classes, there is no point in filing a grievance over it. And if they demand pre-op weight loss that he hasn't done yet, that can, as Diana said, be successfully appealed. But if he can get to Dr. Belzberg and make a good case, he can get a DS.
If he does move to the NorCal region, he will probably need to start the approval process over again, as this is a separate insurance program.
Larra
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