The health group decides...not the insurance?

This is a new one for me.

My group is Facey. I learned something new yesterday and I think I got this right. I called the utilization dept to see if they had got my paperwork from the surgeons office and she said no but she keep keep asking because they don't want their patients waiting. Then she went on to tell me the approval is done by the medical group. They said they have the privelidge of the approval process. The nurses go over it and decide if you are a candidate and sends the approval to the surgeon, then you get a date.

Am I understanding this right? I have an HMO too. Anyone else have this experience?

Howdy,

My experience is that with an HMO the Medical group/IPA will get he first approval /denial. My medical group denied my surgery but I appealed to my health insurance and they approved it. Also, the medical group required a six month diet program but my health insurance did not.


Good luck in your journey.

Hi Melissa   Yes it is the Medical Group that makes the decision to approve or deny WLS, but they do not have the final word it is up to the actual carrier. This is what happened to me. I have Blue Shield of California HMO (Lakeside Medical Group) I have a BMI of 44.3 and asked my doctor to refer me to Dr Quilici for a surgical consultation for Laparoscopic Rou-En-Y. My medical group (Lakeside) denied my doctors request and instead suggested that I see a Dr Lewis and start to do “The Snickers Diet"…. Which I told them No I would not see him and that I was going to appeal the decision. So for the next week or so I raised HECK…. I called Blue Shield of CA and began the paperwork for a grievance appeal. But I did find out that for Blue Shield of California HMO weight loss surgery is a mandated coverage if your BMI is over 40 or 35 with co-morbidity's. I also found out that Blue Shield did not require a 6 month supervised diet (that was just the requirement that the group had) and since I had them overturn the denial I no longer needed to prove my 6 months of dieting. The BMI alone will do. I am very familiar with Facey (I work right down the street and we see lots of Facey pt’s) and If it is of any comfort to you I do know that Facey is good at approving this procedure.  As of now I have had my consultation with Dr Quilici and the Nutritionist on 10/20, my psych evaluation and Support class on 10/21 and now I just am waiting for my authorization for surgery from the insurance co. I just hope they don’t decide to deny me again I have spoken to my grievance coordinator at Blue Shield and she told me she is going to “Baby-sit" my authorization to make sure the group does not attempt to deny me again. I have found that persistence is the main key to getting approved.

The Best of Luck to you...
 

Thank you so much for all that info. My Facey PCP told me that she has never had a patient denied. That is pretty neat that they get to approve it.

What the heck is the Snickers diet??? not the candy is it? lol.

Dr. Q's office faxed over the request for autho on the 23rd...but I called the Facey utilization dept today and they said they did not get the fax So after a few phone calls the U dept called to have them refax. Facey is really on the ball. I've only had a HMO since May of 08 and I'm glad I went that route. My husband and I are self employed so I decided to give an HMO a try to save some money.

Thanks again for the info.