Getting thru Kaiser

Hi...My name is Patty and I have Kaiser HMO. I just went to my first visit with the dietician. Kaiser is going to be changing their requirements in April 2005. All people wanting WLS will have to go thru a 24 week class. Right now the Riverside clinic is a 8 week class. Plus, you have to have been with the dietician for at least 6 months before anything. I am so depressed about this whole procedure. If anyone has any suggestions on how to get around this...who I can appeal to or anything. Also, my husband has open enrollment in Nov/Dec. Is there any insurance company out there that does it right away if you qualify...with no wait. I have a BMI of 48. Thank you, Patty Riverside, CA

There is no getting around Kaiser. The good news is that if you follow their instructions, you will be approved, and have surgery in a few months. As far as your choices during open enrollment go - you will need to do the research. Request copies of the Summary Plan Description booklet for any alternative carriers. Then call them, and ask them to fax you their Utilization Review guidelines for WLS (if covered at all.) Frankly, you are lucky to have coverage for WLS in these screwed up times... Good luck to you on your journey, Roberta

Roberta, Hi....I was wanting and hoping to have the surgery the first part of next year. When I went to the dietician, she said that the earliest I would be having surgery would be a year from now....that is why I was depressed. She also said that I need the 2 co-morbidities. I am going tomorrow for a diabetes test and x-rays of my knees, lower back and feet for arthritis. She suggested that I call my PCP and have him put me on cholestrol medicine and that would count as 1 co-morbidity. My cholestrol is a little high. I don't want to take medication just to get the surgery....my other alternative is to gain 14lbs and then I wouldn't need any co-morbidities. That is sad. Anyways...I am still going thru with it and being patient, I need to do this for myself. Thank you.... Patty Are alot of the insurance companies dropping WLS? If yes, why?

Patty, I know this is frustrating... To answer your question, yes, a lot of insurance companies are dropping WLS coverage. They can't seem to be able to see the forest thru the trees... Insurance companies exist to make money, not to protect your healthcare. The stakeholders scream at the Board of Directors when the reserves (money put aside to pay claims) is low, and the company is not making a profit. Most working Americans are covered by a self insured plan through their employer. In these times, most employers know that the employee is unlikely to be with the company for more than 5 years. They figure that it is more financially sound for them to deny $40,000 and pay for the co-morbidities rather than surgery. However, the trend MAY be swinging the other way. BCBS of NC announced that they will begin to offer more access to WLS. Also, a few weeks ago, JAMA published an article showing how it is much smarter to pay for WLS, than the resulting issues and co-morbidities. The article stressed how Diabetes Type 2 can be totally eliminated in 77% of patients, and high blood pressure and sleep apnea are equally eliminated. In the meantime, have a donut!