Question:
Can someone help with Healthnet guidelines?

I called the management group who decides if iam approved for my surgery and was told there is a new medical director who will reviews all the requests for surgery and he is going to be going through every file to make sure they are medically neccesary. I was told by my surgeons office staff that health net sent them NEW guidelines and one of them is for a medically documented supervisored diet for 12 months !!! Which i don't have. I am told I meet all the requirements before this came to light. I am totally devestated and abosoutley sick to my stomach. What iam going to do ??? Right now as it stands noboby knows anything. This new medical director is going to weed out this type of surgery in order to save this hospital or medical groups ( in their eyes Money) on unneccesary surgeries. In that case why even bother approving me to see the surgeron in the first place??? I just hate it when people say oh just think positive about it. Yeah right !!! I have had health net for 16 years and they have recieved from me over 100,000 dollars from my monthly premiums. Boy o boy, they really got me going !!! Anyone out there dealt with health net hmo in california???? Sure could use everybodys input and adviced. Thanks to all who answer me.    — Laura G. (posted on April 13, 2001)

April 13, 2001
DEAREST LAURA, I TOO HAVE HEALTHNET HMO FROM CALIFORNIA. WHAT I HAVE NOTICED IS HEALTHNET MAKES YOU JUMP THROUGH A LOT OF HOOPS BEFORE GIVING IN. IT TAKES PRESERVERANCE AND DEDICATION WHEN DEALING WITH THEM. ACCORDING TO MY HEALTHNET BOOK I WAS TOLD THAT I HAD TO BE ON A 6MO SUPERVISED DIET PLAN BY MY PCP. I WAS NOT AND I WAS APPROVED. I WAS FOR A COUPLE OF MONTHS BUT NOT THE FULL 6 AS THEY HAD REQUESTED. ORIGINALLY I WANTED THE DS SURGERY AND THEY DENIED ME I APPEALED, BUT THEY APPROVED ME TO SEE A SURGEON WHO DOES THE RNY. FINALLY I AGREED, AFTER ALL BEGGARS CANT BE CHOOSERS:) I WASTED 7MO FIGHTING WITH THEM, BUT WHEN I FINALLY GAVE IN AND LET THEM HAVE THEIR WAY THE APPROVED ME FOR THE SURGERY IN ONLY 2 DAYS!! IM SCHEDULED FOR THE 27TH OF THIS MONTH. IT IS TRUE THAT THEY ARE TRYING TO CUT BACK AND MAKE IT HARDER TO HAVE THE SURGERY BECAUSE TOO MANY PEOPLE ARE HAVING THE SURGERY DONE. MY ADVICE TO YOU IS TO STICK WITH IT, I DONT KNOW YOUR MEDIACL HISTORY OR BMI BUT IF YOUR DOCTOR DEEMS IT MEDICALLY NECESSARY THEN YOU HAVE A CHANCE. YOU MAY HAVE TO FIGHT, BUT IT DEPENDS ON HOW BAD YOU WANT IT!!!STAY STRONG AND STAY FOCUSED, I KNOW ITS DIFFICULT BUT IT WILL BE WORTH IT. THE NEW LAW PASSED A YEAR OR TWO AGO THAT GIVES YOU THE RIGHT TO SUE YOUR HMO IF THEY DO NOT APPROVE YOU,IF YOUR DOC HAD DEEMD IT MEDICALLY NECESSARY. SO THAT ALWSY AN OPTION!! AS FAR AS "WHY DID THEY APPROVE YOU FOR THE CONSULT TO BEGIN WITH" WELL THEY WILL NO QUESTIONS ASKED, THEY DONT REVIEW YOUR MEDICAL HISTORY UNTIL YOU GET APPROVED BY THE DOCTOR, THEN THATS WHEN THEY MAKE THEIR DECISION. BECAUSE THERE NOT LOSING OUT ON ANYTHING BY YOU SEEING THE DOCTOR, THE FIRST TIME. ITS ALL ABOUT THE MONEY!!! I HOPE THIS WAS OF SOME HELP TO YOU? IF YOU HAVE ANY MORE QUESTIONS FEEL FREE TO EMAIL ME AT [email protected]. BEST OF LUCK TO YOU AND I WILL KEEP YOU IN MY PRAYERS.
   — JCNME

April 13, 2001
DEAREST LAURA, I TOO HAVE HEALTHNET HMO FROM CALIFORNIA. WHAT I HAVE NOTICED IS HEALTHNET MAKES YOU JUMP THROUGH A LOT OF HOOPS BEFORE GIVING IN. IT TAKES PRESERVERANCE AND DEDICATION WHEN DEALING WITH THEM. ACCORDING TO MY HEALTHNET BOOK I WAS TOLD THAT I HAD TO BE ON A 6MO SUPERVISED DIET PLAN BY MY PCP. I WAS NOT AND I WAS APPROVED. I WAS FOR A COUPLE OF MONTHS BUT NOT THE FULL 6 AS THEY HAD REQUESTED. ORIGINALLY I WANTED THE DS SURGERY AND THEY DENIED ME I APPEALED, BUT THEY APPROVED ME TO SEE A SURGEON WHO DOES THE RNY. FINALLY I AGREED, AFTER ALL BEGGARS CANT BE CHOOSERS:) I WASTED 7MO FIGHTING WITH THEM, BUT WHEN I FINALLY GAVE IN AND LET THEM HAVE THEIR WAY THE APPROVED ME FOR THE SURGERY IN ONLY 2 DAYS!! IM SCHEDULED FOR THE 27TH OF THIS MONTH. IT IS TRUE THAT THEY ARE TRYING TO CUT BACK AND MAKE IT HARDER TO HAVE THE SURGERY BECAUSE TOO MANY PEOPLE ARE HAVING THE SURGERY DONE. MY ADVICE TO YOU IS TO STICK WITH IT, I DONT KNOW YOUR MEDIACL HISTORY OR BMI BUT IF YOUR DOCTOR DEEMS IT MEDICALLY NECESSARY THEN YOU HAVE A CHANCE. YOU MAY HAVE TO FIGHT, BUT IT DEPENDS ON HOW BAD YOU WANT IT!!!STAY STRONG AND STAY FOCUSED, I KNOW ITS DIFFICULT BUT IT WILL BE WORTH IT. THE NEW LAW PASSED A YEAR OR TWO AGO THAT GIVES YOU THE RIGHT TO SUE YOUR HMO IF THEY DO NOT APPROVE YOU,IF YOUR DOC HAD DEEMD IT MEDICALLY NECESSARY. SO THAT ALWSY AN OPTION!! AS FAR AS "WHY DID THEY APPROVE YOU FOR THE CONSULT TO BEGIN WITH" WELL THEY WILL NO QUESTIONS ASKED, THEY DONT REVIEW YOUR MEDICAL HISTORY UNTIL YOU GET APPROVED BY THE DOCTOR, THEN THATS WHEN THEY MAKE THEIR DECISION. BECAUSE THERE NOT LOSING OUT ON ANYTHING BY YOU SEEING THE DOCTOR, THE FIRST TIME. ITS ALL ABOUT THE MONEY!!! I HOPE THIS WAS OF SOME HELP TO YOU? IF YOU HAVE ANY MORE QUESTIONS FEEL FREE TO EMAIL ME AT [email protected]. BEST OF LUCK TO YOU AND I WILL KEEP YOU IN MY PRAYERS.
   — JCNME

April 13, 2001
What you have working for you is that they have already approved the surgery several times. Use that to your advantage. Just because they want to get tougher now, doesn't mean you don't qualify. Like the previous post says, be persistant and keep fighting. The companies try to save money but eventually they know when to quit if you qualify for the surgery. Good luck and keep us posted.
   — Dawn R.