Urgent: Legal question regarding surgery approval

This question goes out to anyone who might have some advice for me. I have Blue Shield of California HMO and am with a medical group called PrimeCare of Inland Valley. In September 06 started my journey of supervised weigh loss with my then new PCP who gave me weight loss meds, weighed me and so forth. In February 07 upon being unsuccessful, I discussed with my PCP possibility of bariatric surgery and he said he thought I was a perfect candidate and should not have a problem getting approved. I confirmed with medical group if it was covered, which it is, with the same requirements, 6 months doctor supervised weight loss within 2 years, BMI over 35, etc. My PCP asked that I formally write up a list of all my weight loss attempts as far as I can remember (I have been overweight all my life) and type it up and submit it to his assistant who will be my contact person. In April 07 submitted my documents to my PCP's assistant. I was laid off in late April and my medical coverage terminated on May 1. I called the PCP's assistant in early May to explain the situation and inform her I would be extending my coverage via the COBRA act and that I would appreciate her expediting the process for. She assure me everything had been submitted and that we are now waiting on authorization. It has been torture trying to get my PCP's office to cooperate and send in my paperwork. Specifically, the young lady who is my contact has been very rude and unprofessional. Initially, she assured me she had submitted everything. Then she changed the story and said she submitted it and the insurance sent it back. Then she said that my paperwork was still sitting on the doctors desk and he needed to review it. Three months of this. I have called periodically the medical group, who has been gracious enough to give me all the information they can but my PCP's assistant has NEVER returned a phone call after numerous messages nor have they updated me as to the status. I filed a complaint with the medical group regarding how dissatisfied I was with the office staff and I think that may have made it worse. Finally on 7/09/07 they submitted my documentation and the medical group review it the same day and contacted my PCP's office regarding needing additional information. As soon as I found out I called, again, was not put through and had to leave a message for the assistant in charge of my case at my doctor's office. Needless to say she still has not returned my phone call. I got the formal letter in the mail from the medical group that states : "Need information on Supervised weight loss program notes within last 2 years and the check list completed." My doctor should have all of this,because he is the one who was treating me with the presciption weight loss meds since September 06 and has been documenting my weight since then. I did not, however have medical coverage prior to August 2006. Still, its within 2 years. And what is a checklist??? I don't know why my doctor's office is makign this so difficult and think my last ditch attempt will be to  FAX over a letter stating that I need this matter to be addressed immediately and maybe attachign a copy of the letter I received from teh medical group. Can anyone give me suggestions as to what I can say in the letter? Do I have any legal rights that can force my physician to 'get on it' or threaten them with filling a grievance? I feel like I just paid my premiums, while I was unemployed, for nothing! I truly feel like this lady is doing all of this on purpose, to get back at me for the complaint (which was truly legitimate). Please help...Thank you.

Hi there, I just read your post.  I too am pre-op and waiting for my surgeons office to submit to Cigna all my paperwork, whi*****ludes everything that I have complied with since December '06. I really felt bad that you are having such a time with your PCP's office. I too had such a head'ache and heart'ache trying to get the office personnel to please please please make sure that they do everything proper. One time when I finally finished my 6 month Dr. superv. diet thru their office, ...just like Cigna required....I would always hand the nurses my detailed diet and a separate printed calandar of all my exercise requirements, and guess what.......3 of the months,,,they 'forgot' to notate on my chart that I had done that. I was very careful to do everything perfectly. So one day, I called the nurse to remind her to notate the charts....she said....'how can I do that? How do I know what you ate, you could have written down anything' I felt like screaming. I even had my husband go into the office to talk to them about it.    To him they acted like they were going to do it. I went to the 'records dept', and sure enough, when I myself researched everything,  they had NOT notated anything about the diet or exercise sheets that I so diligently gave them. At this point, I am just hoping Cigna will just accept the limited info on my charts, and maybe things will work out. My PCP is great though, he wrote a nice letter for me that I hope will help. It's just his office that sucks. I feel now that I don't even want to use my PCP anymore, as  I imagine the nurses Hate My Guts, because i have 'bothered' them so much. People don't realize that this is a last resort for some of 'us'. and we are literally dying if we don't do something. After all that,.... my surgeon 'forgot' to sign a letter in my Cigna package ,that little mistake is going to cost me  so now even though I am good to go RIGHT NOW, because he is on a 3 week vacation, now I am set back another month at least for Cigna to examine my materials. As for a letter, I am not sure.  There is a genius guy here in this insurance forum named Paul, who you can contact and always has something wise to say. Also I hope Gary might chime in. Ha,  now that I think about it, your post just pi$$$e$ me off, because you have done all you were supposed to do....................OHHHHHHH.     I hardley ever post, but you have brought me out of 'retirement, so to speak'.       Please keep me up to date with your case. Wish I could fix it for you.

Vicky: THANK YOU SO MUCH for sharing!!! I feel like somebody understands me and I'm not just crazy. Since I know what it feels like, I'm really sorry to hear you are going thru almost the exact same thing. I know the feeling, when you have to call the office to "bother" the nurses with a question or to get an update and they act like you are asking them for a kidney. AAAAAAAARRRRRRRRRGGGGGGHHHHHHHHHH!!!! I think what bothers me the most is that I have confided in my PCP my fiancial problems since losing my job, and how much of a burden having to pay for all my healthcare premiums out of pocket (since  obviously my employer doesn't anymore) and how I hoped that they woudl take that into account when working on my file. I reiterated that the ONLY reason I elected to continue my own health care coverage was because I had gotten SO FAR in the whole process and was hoping to get approval for surgery. That's all I want. I want a yes, or a no. I will be elated if I am approved, but I will accept a no and move forward if that's the case. I just want an answer. Right now its like I'm just wasting my money and I am at their mercy. Anyway, I"m babbling. I really hope your surgeon gets it together and finalizes everything for you. I'll keep you in my thoughts and prayers. Good luck to you, best wishes and thanks so much for replying! :)

Oh my, on top of it you are a person that has to pay for insurance on your own?  Now I really hope you get approved!! That part about you saying you feel like you may be waisting your money, and am at their mercy...... is a recurring cry heard here on this forum. Look up that Paul guy, and see if you can get him to post. He helped me,  slowed me down and made me think.   What kind of surgery are you going for.   I am 50 yrs old w/ a BMI of 36 with a plethera of co-morbs. I am trying to get Cigna to approve a  Sleeve Gastrectomy that they normally don't do because it is 'experimental', however I have reasons I hope they will agree with. Never feel as if you are 'babbling', as that is what these forums are for.  We are all in the same ship. ( I almost said the same 'fat bucket', but ha....don't want to get any politically correct people mad at me.....  darn, did I just say that? ha)

Thanks for the info Vicky, I'll definately look him up :) I don't think 'fat bucket' would be politically correct, but maybe "chunky chair"?? LOL. Just kidding people!! :) I am 28, have no co-morbs aside from depression but I have a BMI of 50. I am currently at my all time highest weight of 285. I don't have proof of any Weigh****chers or programs such as those in the past, so the only weight loss attempt "on record" so to speak, would be with my current PCP who prescribed to me a medication called Bontril back in September 06. I have been in for follow-ups periodically since then, where I have been weighed and such. So I don't know if I will be approved or if they will require a nutritionist or weigh****chers or something. I just feel like this is my last chance :(  I did supply my PCP with a long list of weight loss attempts dating back 10 years which took me forever to come up with - but unfortunately its nothing that is verifiable. My PCP doesn't seem to think there will be a problem getting me the surgery (although at the rate he is going with the referral, you'd think the documents were being sent via messenger pigeon). All I know is that as soon as my PCP's office does their part in sending in all the proper documentation, regardless of whether I am approved or not, I will NEVER go back to that office again. This is been the worse experience I have ever had with a health care provider.

I had problems getting an answer from the referral dept. at my PCP's office. They never called me back, etc. so finally, I walked in, WITHOUT AN APPOINTMENT, and said "I need to talk to someone. NOW."  They got me a person who was in charge, I told her what I needed. You just have to force their hand. The second time, I called, and then faxed her, and left about 4 contact numbers, my email, and my fax number, with a note to "Please do this ASAP, then call me and let me know when you have done so." Being direct like that, I got an answer within 24 hours. Now I don't put up with any bulls***. I do what I have to and push and push and push till I get the answer I want/need. If your contact person at the office is not doing her job, schedule an appointment with your PCP and lay into him about how their delays are affecting you. Be firm, but polite. Don't swear, but do say "This is what needs to be done, and it is not happening. X keeps telling me different things. I want this taken care of TODAY, and I want confirmation, TODAY."

You have the legal right to your medical records, and you can always send them yourself if you have to.  Sometimes it pays to just be sure. I've never heard of  a checklist, but usually with diet history they like to see a letter, and chart notes. 

Just read your post and I used to have bcbs of california through riverside county. There is a checklist that I got from my doctor's office whom bcbs submits to md's office for approval for the surgery. If they don't have it, then they are probably not used to dealing with weight loss surgery. I would ask the surgeon's office or bcbs myself and if you do call bcbs you might as well have them email the weight loss surgery requirements from the handbook. It is always nice to have because it is concrete and set in stone, and if you talk with someone and they say they do not do this or that, you can always refer back to the booklet and say well I am looking at this right now and it is written on page, etc,etc. Good Luck!!!

thanks everyone for your input - I really appreciate you all taking the time to reply. Unfortunately I can no longer continue my healthcare coverage, and of course, my PCP's office has not submitted the appropriate paperwork. I've just run out of time because my insurance will lapse on August 1 if I don't pay and I just can't afford it anymore - especially if they are taking so long to to process the referral. Thanks again and good luck to everyone.

You know as much as we pay to go to the dr, they have on right to treat you like crap.  I know i would've charged into the office.  It's hard for them to ignore you in person.