Question:
Should I change PCP's?
My PCP has stated that although he has referred patients for WLS in the past, he has never had a patient get approved. So while he's willing to do the work and give me the referral, I'm wondering if his lackluster enthusiasm colors how he presents the package to the insurance company. I have Kaiser and need to go through 6 monthly meetings with a nutritionist before the paperwork can be submitted. But my PCP said he'd see me in 3 months so we can finish the remaining tests that need to be completed for approval. So I'm real torn. He acknowledges that WLS is the only proven successful strategy for the morbidly obese to lose weight, but he thinks my lack of serious co-morbidities will prevent me from getting approval. Can my own heart felt letter to the evaluator help sway the decision? — antiques55 (posted on May 14, 2003)
May 14, 2003
Hi, I can't say whether or not you should change Dr's, but I can address
the letter to the insurance company question. I was approved just 3 days
after the ins co revieved the packet from my Dr. The packet included a
letter from me. The reviewer said that my letter had the greatest impact on
their decision. I didn't get emotional I just stated facts. It summarized
diet attempts, how my weight impacts my daily life, what my future could
hold due to my weight, what costs they may to incur in the near future due
to my weight, my family medical history and current co-morbid conditions. I
was 110lbs over weight. I have a PPO not Kaiser. I have a friend trying to
go through Kaiser and I can tell you that she has a lot of co-morbities and
Kaiser keeps putting up road blocks in front of her anyway. Every Kaiser
Doctor she has seen has recommended the surgery including the Psych. So it
may be your Kaiser group, not the Dr.. If you want a copy of my letter to
the ins co email me and I will send you a copy. Best of luck,
— M B.
May 14, 2003
with a BMI of over 50 you should qualify even withn no co morbids
— bob-haller
May 14, 2003
Doesn't the WLS surgeon apply for insurance approval? The only thing my
PCP did was provide documentation and the referral to the surgeon, who was
the one to apply for approval.
— mom2jtx3
May 14, 2003
I doubt a heart felt letter would do anything. Frankly, they don't care.
But, if you do write a letter, just remember what they're looking for...to
save themselves money. So, your letter should be full of facts that make
them see how much NOT approving the surgery will cost them in the long run.
You may want to go see an orthopedic surgeon if you're having any knee,
leg, hip or back pain due to the excess weight, and if he's a WLS-friendly
ortho guy, get a letter from him, too, recommending surgery. Also, make
sure your PCP documents any co-morbs you do have, such as urinary
incontinence or acid reflux, etc. Just remember, it's all about
money...sad, but true.
— Leslie F.
May 14, 2003
I went through the same thing. My PCP was not even willing to refer me. He
had the attitude that it was all my fault that I weighed so much. He even
told me that all I had to do was change my attitude and I would lose the
weight. One of his nurses told my husband that it was his fault because he
let me do whatever I wanted and he needed to control me better. Needless to
say, I did change PCP. My new one is the most kind and courteous. I
absolutely love him. He suggested WLS before I had the chance. Check with
people in your area to find WLS friendly PCP. And remeber, your PCP can't
stop you, you may have to remind him that you are paying him to treat you.
— Karin C.
May 14, 2003
Linda: Not with Kaiser. Kaiser sends all documentation to an independent
evaluator and they won't give you a referral to a surgeon until you are
approved. Kaiser's guidelines state that if you have a BMI of 50 or more,
that alone is sufficient for approval. But my PCP said he's had other
patients he has referred with a high BMI and no co-morbidities and they
didn't receive approval. I don't know if he's being truthful or if he's
just trying to say anything he can to discourage me. I'd rather lose the
weight without surgery (who wouldn't) but if I don't see a substantial drop
during the 6 months of doctor supervised weight loss, I am prepared to make
sure my PCP does what is necessary and I'll write a compelling letter to
the evaluator. I think my old PCP and the surgeon who did my cholesectomy
would both add their letters of recommendation. I think I might get
greater support from my PCP if I consider a lap band as opposed to RNY
since it's reversible if I experience complications. That's fine with me.
And the surgeon who did my cholesectomy does lap bands and I think he's the
greatest.
— antiques55
May 14, 2003
Here's my take on this: If you have this lack of faith in your physician I
would suggest changing doctors. Our PCP should be VERY in our corner!
— [Deactivated Member]
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