Question:
Need help getting approval to go outside network for DL/Switch

There are no WLS surgeons in Washington that do the DL/Switch. The closest surgeon is in Portland, Oregon [200 miles away]. . I am convinced that the DL/Switch is not only the right surgery for my personal situation, (53 BMI) but I believe it is also has a far superior outcome. Pacific Care pays for the DL/Switch in Calif., Oregon and for Washington patients (who must go to Portland). . The actual medical practice HMO that my PCP is affiliated with contracts with Pacific Care for my care under Secure Horizons, the Medicare HMO portion of Pacific Care. My medical PCP's HMO has denied the surgeon I want because he is out of network. I told them that I would go to any network surgeon who does the DS/Switch but since there is none, I would travel to Portland at my expense for the surgery. Their position is that I must see a network surgeon even if that means having an RNY. . Secure Horizons/Pacific Care, my health coverage HMO will support me if I choose to switch to another PCP with a more cooperative referral policy. However, the last 3 PCP's I've had all quit their affiliation with Secure Horizons without warning and the one great PCP I had refused to refer me for philosophical reasons. He said that if I find another doctor to do the referral, he would follow my after-care. . The problem with an HMO is that one cannot just look in the yellow pages and keep trying different doctors. In addition to there being a limited number of PCP's to choose from, members can only switch PCP's once per month. I am at a loss as to whether I should quit Secure Horizons and go straight Medicare so that I will have more autonomy in this decision. I really like my actual medical PCP. She is terrific; it is her medical practice HMO that is running interference. I also hate to leave Secure Horizons/Pacific Care; they have taken great care of me in all my other medical needs. They are not the problem; the HMO that actually delivers the health care is the problem. . Any suggestions? I am good at advocating for myself but I do not want to fight this alone. I have absolutely no support system in my life so if anyone can offer ideas, I would be grateful. Thanks much. My consult with Dr. Welker is for February 10.    — gobo T. (posted on November 30, 2000)

November 29, 2000
I would suggest you educate the family PCP on the operations offered. I did.. I downloaded all the procedures and the pro's and con's and wrote a letter explaining why I want DS rather than the others.. I think it is Heidi who has a great web site on the pro and cons. I don't have her address on this computer but if she would post it again.Waves to Heidi! i used her site as a reference..okokok so I stole bunches of information. I also have a HMO and am dealing with out of state surgery. I don't know if mine will cover it but I found out by educating my PCP he got behind me in my fight for surgery.One thing I have learned in this fight is 90% of the effort to get what we want will be with our own effort fight fight fight!
   — Debi V.

December 4, 2000
Here's my website address: <a href="http://www.mywls.com">http://www.myWLS.com</a>. You can look on my Insurance page to look for insurance information & my Pro's & Con's that Debi was talking about is on the Duodenal Switch page. Good luck in your fight!! It's worth it a thousand times!!! hugs~~
   — [Deactivated Member]