Question:
Doctor is Not Wanting to Write a Referal Letter!

Last month, my PCP was very supportive and willing to help me get surgery approval. He wanted me to have a sleep study first and then he would send a letter requesting a consult to the insurance. Well, due to several time contraints, I have to have surgery in December or wait an entire year. Obviously I don't want to do that. So I called his office and asked that he go ahead and request surgeon consult. By the time that got approved and I got back from my consult, my sleep study would be over with. THen we would have that additional information to to the insurance company with. Today I got a call from his office stating that the insurance company will not pay for the surgery. His nurse did not know if he had even called the insurance company. I asked because I don't understand why he would just up and contact them. He is a new doctor to this state, and as far as I understand does not deal with the insurnace company, his office does. I am almost 25, weigh 375 lbs. have GERD, some mobility issues, possible sleep apanea, back problems, and stress incontinence. I did tell his office to tell him that I would like a letter despite his feelings of insurance non-payment. If he does not feel that he can give that to me, I'll find someone who can. My insurance has paid for this surgery before, it's a bit difficult but can be done. I guess, I just need to know if anyone has had this situation before. I do not understand why he would just up and call the insurance company about it, when he wanted to wait for a sleep study to begin with. Am I just being unreasonable and he knows what he's talking about. Sorry this is so long, but any advice would be great. Thanks    — Jenifer S. (posted on September 8, 2000)

September 8, 2000
No, you're not being unreasonable. I too was in a similar predicament with my doctor. At nearly 300# pre-op, she said I wasn't morbidly obese and that my insurance would never pay for it. Both of those statements were lies. I was morbidly obese and both of my insurances paid for this type of surgery. However, I've never been one to let someone control my life/destiny. She would'nt give me a referral so I chose another physician and used my PPO insurance instead, that way I didn't require my new physician's approval/referral letter. I was flying solo so to speak. My advice to you is to find another physician and quickly. I am now about 3 months post-op and doing great. Good luck to you, I hope it all works out.
   — PrettyHotAndTempting

September 9, 2000
Hi, No, is NOT an option - find a new doctor. You may want to call some of the weight loss clinics in your area to get their recommendations of wls friendly doctors in your area. Are you sure you need the referral? I didn't get a referral from my PCP, instead I just went directly tot he wls clinics for the consultatation. Also, you can learn lots of tips by going to the free weigh loss seminars most of the wls clinics hold - I went to three and that's where I got a lot of useful information regarding dealing with doctors and insurance. It also gives you a better understanding of that particular doctor's program. Most wls clinics are more than happy to give you suggestions and advice about how to get referrals and insurance approval - after all that's what gets them the business and I have found most clinics very helpful.
   — Jennifer L.

September 9, 2000
Change PCP and don't waste any time! The surgeon's office should be the one's submitting to the insurance company, not your PCP! The surgeon is the one who knows what the insurance company requires and how to submit the paperwork for the approval. My guess is that your PCP's physician group is the one that denied the surgery (by denying a surgeon consult), not the insurance company. I didn't know that this could happen, but this is exactly what happened to me. I had to change PCP's to get a surgery consultation. Do you know who you would like to perform the surgery? If so, ask them who they would recommend as a PCP that is WLS friendly. Then change to that PCP. Or, research your insurance and try and find someone in your area with your insuarance that has had surgery and switch to their PCP.
   — Gina E.