Need advice (insurance/dr stuff)

I am so frustrated with my insurance and doctors it's not even funny. I am at the point where I don't know what to do anymore.

I have medi-cal/anthem for my insurance. I am trying to get a DS because it is the best one for me (I need my nsaids, it has the highest weight loss maintained, type 2 diabetic, high bp, high chol/tryglyc, physical disabilities from weight) and I keep hitting dead ends. I know for a fact the anthem part of my insurance covers it, it just needs to be medically neccessary, etc. which I assume it is with a bmi of 47 and the diabetes.

Anywho, been with this pcp since may and I don't like them but ive stuck with them because every other dr ive been to has said no or only believes in the band if i lose 40 or so lbs. I don't want the band, I want the DS! (no offense to those thats had it, its just not for me) And I finally get a surgeon in november, not sure why the office liked to take their sweet time but they did. And he doesn't do the DS and he doesnt like to do it if the patient cant walk a whole bunch. I ride a bike due to the physical disabilities for exercise but i guess thats not good enough for him. Anywho, I find 1 dr in california that does the ds and takes medi-cal. only 1 in the entire state! I give the name, fax, and phone number to the dr and they tell me it's submitted.

So I call anthem. A nice guy said he'd help me and told me what i'd need to do and that he'd call back. Well he never called back so the next day I called anthem and got another stranger, who seemed to be having a bad day. I could tell he got frustrated with me but oh well. I was a woman with a purpose and got to the point. He gave me some bologne speech about to call and follow up with the pcp. I tried to argue and state my case but to no avail. He said my dr submitted the referral with...and get this...The friggin first/old surgeon's name!!! omg! Is this really happening? I am so angry, and I admit it could be the pms talking. I do believe you can only submit referrals for something so many times, anyone know for sure?

I have an appointment on thurs to ask , yet another 'new' dr at this practice, for a referral/second opinion. The last time I tried this it did not go well. The lady said I needed to lose more weight first and something about a band. I am not even sure what to ask for at this point. I know you can self pay a consultation and then have the surgeon write why you need the DS to the insurance but is there anything else I can do at this point to get the consultation? I don't want to self pay and go all this distance if they really can't/won't pay for it. Also, I am supposed to leave on the 6th to go down to this dr (8+ hr drive) for a seminar. Should I postpone this until I figure out things with my pcp? I believe they do them once a month. Or should I just self pay a consult and try to get a new pcp? Thing is, I can get a new pcp but if they don't like wls or won't refer me, I have to wait a whole month to get a new one because anthem only lets you change at the beginning of the month. Plus with a new dr it might be harder to get it approved since they aren't familiar with me.

I am so confused and frustrated! not sure where to go from here..any advice appreciated  
 

I know its a bit of a struggle, I hope this works out for you.
I would reschedule the seminar/consult, and get an appt in soon with a new pcp and make sure he/she sends in the right referral. Hand him the name, hospital, address, fax of your to be surgeon, and tell them this one. Stress that you are there to talk about wls, and you are going with the DS, that you are in need of a referral to see the surgeon. Don't ask, tell!

What is your bmi? How long have you been in the obese category?


Good luck hun, I hope things get on track fast. I been waiting 4 years.

My bmi is 47, been overweight as long as I can remember, even as a kid. Remember the sizes better than the weight as a kid tho lol. Been over 200lbs since before I turned 18 tho

I feel your pain hun.  The insurance phase is so disconcerting because you don't know what direction you should go. Be good to yourself and get the answers you need so you don't waste your time and energy.

Keep the faith,

me

I know this won't solve the whole problem, but if you can, get the name of a specific person at Anthem that you can talk to every time. Otherwise, you will go round and round with a different "stranger" every time. Maybe a supervisor or manager? 
      And if possible, sit there with the person at your pcp's office who does the referral and make sure they get it right. Do it in a nice way, or course, just being helpful and all.

Larra

I hope you are asking for a referral to Dr. Keshisian. (Sp) Keep working at it with Larra's advice. It is soooo worth all the effort. Hope the process speeds up for you-good luck.

Dr. K doesn't take medi-cal. Dr. Crookes is the only one in california that does

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 Hang in there. I believe your tenacity will pay off. I am also waiting for approval from my insurance and have the same co-morbidities that you have. If I do not receive a response by next week, I will have to make some phone calls myself. Good luck. God bless.

 
Dr. Crooke's office should be able to help advocate for you with your insurance, and figure out exactly what you need to get approved.  It's often simpler to work from the surgeon's side, since it's in their best interest to work hard to get paid.

As far as PCPs and referrals, let your new doctor know that you're likely to be required to do a six month weight monitoring program prior to surgery, and you can talk to him/her then about "losing more weight."  Just reiterate that there are at least four different bariatric surgeries, and you're not interested in getting a band.  They will get it eventually.

If you're doing a consultation with the doctor, that's by appointment.  It sounds like it's an information session on the different types of surgery.  You can attend that whenever it's convenient for you, and consult with the doctor by phone if needed.

I hope everything works out well for you!