Re: Did I Mention How Much I Hate Rollercoasters?

[Guest guest]

My Dog!! These people are treating it like a game! This is deplorable!!

Did I Mention How Much I Hate Rollercoasters?

Here's the latest, after 1.5 hours on the phone with

Marin IPA and Pacificare:

Per Kmetz (Marin IPA), Pacificare doesn't cover

the DS because DS Surgery includes lots of " extras "

that they don't cover. When I tried to find out what

the " extras " were, she couldn't tell me. She said to

call Pacificare and get past the Customer Service

reps, preferably to a Case Manager. By the way, she

seemed to find something funny about the whole thing,

laughingly saying how Pacificare has " been down this

road before " (DS vs RNY) and DS just isn't covered.

So I called Pacificare again and spoke to

Pereira. I asked to speak with a case manager and,

after being put on hold seven minutes, she came back

to tell me case managers don't talk to people about

this kind of surgery (!?!) OOOOOooooooooook, so then

we got down. I told her why I didn't want the RNY,

the differences between the two surgeries and asked

again to be referred to Dr. Rabkin. She said the

reason I was referred to Dr. O was because he was in

network. I told her the referral letter said he

wasn't. She said he's on the list to refer people to

when a doctor isn't found in-network.

So I asked her to look up Dr. Rabkin. Sure enough,

he's there too! I repeated my request to see him.

She said Dr Rabkin does other kinds of surgery and

that's why he's on the list. Then she kept telling me

that Pacificare does NOT cover the DS and they do not

approve it for anyone. I told her about these

e-groups and that Pacificare is definitely mentioned!!

I was put on hold three times for a total of 40

minutes so she could talk with her supervisor. In the

end, she said I couldn't even appeal the declination

as I wasn't actually declined in writing! (Jesus,

and ph!!!) She even said I was actually

approved for the RNY not just for the consultation.

(Oh joy).

I kept insisting on speaking with someone above her

and the 3rd time I asked she said " why didn't you

ask? " .... She put me on hold for 12 minutes and then

came back saying there were no supervisors available

but I could talk with a " mini-supervisor " ... I'm

thinking of Austin Powers and Mini-me now...

Finally, I get to talk with Yolanda Moffit and I

explained everything again to her. She said the DS

isn't covered and no one with Pacificare has had the

surgery, she's sure of it. I told her to log onto

obesityhelp.com and find out for herself! I also told

her about the delay tactics I've heard about

Pacificare and that they seem to be true. I told her

I didn't want to see Dr because of the type of

surgery she does and her inexperience. I asked

Yolanda if she would like the quality-of-life people

with RNY patients have vs. DS patients. Heck, I have

trigger points all over my head - there's no way I

could chew chew chew my food!

In the end, she said to see my PCP and have him write

out a specific request to see Dr. Rabkin and we'll go

from there.

I'm exhausted. How do you guys handle this?

Thanks for wading through this novel.

=====

Dee

Waiting for Ins. Co. Approval

313/Want to be 165

__________________________________________________

[Guest guest]

I'm exhausted. How do you guys handle this?>>>

Hi Dee! Im exhaused just reading all of this becuz it sounds exactly the

same as I was put thru with Regence BC/BS! (Incidently did you know BS

stands for Bull **it??)

They tried telling us EXACTLY the same things you were told......that they

do not ever approve the DS (or RNY) and have never paid for one but I had

proof they did becuz they sent me (by accident) this paper that proves what

they do pay for and the RNY and the DS were amongst those listed! They

denied us twice in appeals. After talking with Walter I knew once it went

to the medicare review board (medicare does pay for both surgeries) that

they would be overturned and that is exactly what happened! (Incidently, Dr

Welker helped Regence write their policy!) They even lied to medicare about

there not being ANY surgeon in their network (which covers Washington,

Oregon and Idaho) who does either kind of surgery and that the surgeons

consider it too dangerous to do either of them! (

I wonder how stupid medicare must think these insurance companies

are???)

I had the greatest pleasure in calling them after they were overturned and

telling them to get on the ball and set up the paperwork for the surgery as

we already had a date!

Geez........you would think since medicare approves these kinds of surgeries

they would know what is experimental and what isnt!

You hang in there now!!

Judie

[Guest guest]

OH LAWD!!! What a run around!!! Look at it this way...so you spend a few

HOURS (maybe days) on the phone now....but you live with this surgery the

REST OF YOUR LIFE! I feel that it will be worth the fight!! I, too, am

fighting insurance....I was given the " wrong " policy book by my husband's

employer, then they " lost " my pre-cert....then they found it in May after I

called to question the status( I had seen Dr. Booth Feb 7) then I got the

" right " policy booklet...and the " criteria " for surgery has totally

changed!!! Had to change PCP because mine feels that WLS is a " tragedy that

people do to themselves " !! So many people (and doctors) know so little

about the surgery that I've had problems finding a WLS friendly

PCP...finally have I have an appointment for Sept. 11 to see if she can help

me push past all the " criteria " do-do!!! Keep us posted...I will have the

DS or BUST!!! I hope!

Hugs and good luck wishes

Jerry, southern gal from Louisiana

>

>Reply-To: duodenalswitch

>To: duodenalswitch , DS_PacificLaparoscopy

>Subject: Did I Mention How Much I Hate Rollercoasters?

>Date: Mon, 27 Aug 2001 16:09:23 -0700 (PDT)

>

>Here's the latest, after 1.5 hours on the phone with

>Marin IPA and Pacificare:

>

>Per Kmetz (Marin IPA), Pacificare doesn't cover

>the DS because DS Surgery includes lots of " extras "

>that they don't cover. When I tried to find out what

>the " extras " were, she couldn't tell me. She said to

>call Pacificare and get past the Customer Service

>reps, preferably to a Case Manager. By the way, she

>seemed to find something funny about the whole thing,

>laughingly saying how Pacificare has " been down this

>road before " (DS vs RNY) and DS just isn't covered.

>

>So I called Pacificare again and spoke to

>Pereira. I asked to speak with a case manager and,

>after being put on hold seven minutes, she came back

>to tell me case managers don't talk to people about

>this kind of surgery (!?!) OOOOOooooooooook, so then

>we got down. I told her why I didn't want the RNY,

>the differences between the two surgeries and asked

>again to be referred to Dr. Rabkin. She said the

>reason I was referred to Dr. O was because he was in

>network. I told her the referral letter said he

>wasn't. She said he's on the list to refer people to

>when a doctor isn't found in-network.

>

>So I asked her to look up Dr. Rabkin. Sure enough,

>he's there too! I repeated my request to see him.

>She said Dr Rabkin does other kinds of surgery and

>that's why he's on the list. Then she kept telling me

>that Pacificare does NOT cover the DS and they do not

>approve it for anyone. I told her about these

>e-groups and that Pacificare is definitely mentioned!!

>

>I was put on hold three times for a total of 40

>minutes so she could talk with her supervisor. In the

>end, she said I couldn't even appeal the declination

>as I wasn't actually declined in writing! (Jesus,

> and ph!!!) She even said I was actually

>approved for the RNY not just for the consultation.

>(Oh joy).

>

>I kept insisting on speaking with someone above her

>and the 3rd time I asked she said " why didn't you

>ask? " .... She put me on hold for 12 minutes and then

>came back saying there were no supervisors available

>but I could talk with a " mini-supervisor " ... I'm

>thinking of Austin Powers and Mini-me now...

>

>Finally, I get to talk with Yolanda Moffit and I

>explained everything again to her. She said the DS

>isn't covered and no one with Pacificare has had the

>surgery, she's sure of it. I told her to log onto

>obesityhelp.com and find out for herself! I also told

>her about the delay tactics I've heard about

>Pacificare and that they seem to be true. I told her

>I didn't want to see Dr because of the type of

>surgery she does and her inexperience. I asked

>Yolanda if she would like the quality-of-life people

>with RNY patients have vs. DS patients. Heck, I have

>trigger points all over my head - there's no way I

>could chew chew chew my food!

>

>In the end, she said to see my PCP and have him write

>out a specific request to see Dr. Rabkin and we'll go

>from there.

>

>I'm exhausted. How do you guys handle this?

>

>Thanks for wading through this novel.

>

>=====

>Dee

>Waiting for Ins. Co. Approval

>313/Want to be 165

>

>__________________________________________________

>

[Guest guest]

So, I have Pacificare and I have an appointment to see my physician for a

referral,I'll wait to find out from you what type to tactics to use to have

my physician write out a referral for DS to Dr. Ara K. at his modesto,ca.

clinic.

Keys...........

Did I Mention How Much I Hate Rollercoasters?

> Here's the latest, after 1.5 hours on the phone with

> Marin IPA and Pacificare:

>

> Per Kmetz (Marin IPA), Pacificare doesn't cover

> the DS because DS Surgery includes lots of " extras "

> that they don't cover. When I tried to find out what

> the " extras " were, she couldn't tell me. She said to

> call Pacificare and get past the Customer Service

> reps, preferably to a Case Manager. By the way, she

> seemed to find something funny about the whole thing,

> laughingly saying how Pacificare has " been down this

> road before " (DS vs RNY) and DS just isn't covered.

>

> So I called Pacificare again and spoke to

> Pereira. I asked to speak with a case manager and,

> after being put on hold seven minutes, she came back

> to tell me case managers don't talk to people about

> this kind of surgery (!?!) OOOOOooooooooook, so then

> we got down. I told her why I didn't want the RNY,

> the differences between the two surgeries and asked

> again to be referred to Dr. Rabkin. She said the

> reason I was referred to Dr. O was because he was in

> network. I told her the referral letter said he

> wasn't. She said he's on the list to refer people to

> when a doctor isn't found in-network.

>

> So I asked her to look up Dr. Rabkin. Sure enough,

> he's there too! I repeated my request to see him.

> She said Dr Rabkin does other kinds of surgery and

> that's why he's on the list. Then she kept telling me

> that Pacificare does NOT cover the DS and they do not

> approve it for anyone. I told her about these

> e-groups and that Pacificare is definitely mentioned!!

>

> I was put on hold three times for a total of 40

> minutes so she could talk with her supervisor. In the

> end, she said I couldn't even appeal the declination

> as I wasn't actually declined in writing! (Jesus,

> and ph!!!) She even said I was actually

> approved for the RNY not just for the consultation.

> (Oh joy).

>

> I kept insisting on speaking with someone above her

> and the 3rd time I asked she said " why didn't you

> ask? " .... She put me on hold for 12 minutes and then

> came back saying there were no supervisors available

> but I could talk with a " mini-supervisor " ... I'm

> thinking of Austin Powers and Mini-me now...

>

> Finally, I get to talk with Yolanda Moffit and I

> explained everything again to her. She said the DS

> isn't covered and no one with Pacificare has had the

> surgery, she's sure of it. I told her to log onto

> obesityhelp.com and find out for herself! I also told

> her about the delay tactics I've heard about

> Pacificare and that they seem to be true. I told her

> I didn't want to see Dr because of the type of

> surgery she does and her inexperience. I asked

> Yolanda if she would like the quality-of-life people

> with RNY patients have vs. DS patients. Heck, I have

> trigger points all over my head - there's no way I

> could chew chew chew my food!

>

> In the end, she said to see my PCP and have him write

> out a specific request to see Dr. Rabkin and we'll go

> from there.

>

> I'm exhausted. How do you guys handle this?

>

> Thanks for wading through this novel.

>

> =====

> Dee

> Waiting for Ins. Co. Approval

> 313/Want to be 165

>

> __________________________________________________

>

[Guest guest]

I worked at an insurance co. as a nurse case manager---

There is alot of the left hand not knowing what the right is doing. THere

are also people who " claim " to know everything there is to know about

coverage--then the next one makes a liar out of them.

So, knowing that--here's the strategy---when someone says no, you get their

name---then ask for some one diffferent---their supervisior or if they can't

get you someone call at a different time and wait for the operator--say you

want to speak to someone other than so and so, yet with someone in the dept.

(usually prior authorization unit). The company I worked for had a unit of

10 people that just took prior auth calls all day. they were next door to

the nursing case management dept, Most of these people don't know squat

about medical stuff, and they were always asking us to explain what

procedures were.

Keep trying to get someone different until someone says yes--when they

do--request that they immediately put it in writing and fax it that day.

Once they put the yes in writing--they can't undo it. Make sure that they

also update your claims file with specific notation that they said yes.

This is usually an electronic file--so then when the claim comes in--the

analyst sees the notation and pays it, even if the ICD9 code spits out as an

unapproved--many things are approved " out of certificate " --and this notation

verifies it.

It can be a game of semantics -- they approve WLS they can't be predjudicial

as to the procedure. See where this gets you.

Pammi

Re: Did I Mention How Much I Hate

Rollercoasters?

In a message dated 8/27/2001 4:10:13 PM Pacific Daylight Time,

donna_lee777@... writes:

> I'm exhausted. How do you guys handle this?

>

>

Dee...

I'd be exhausted also. I am so upset about these insurance companies. I

understand the money issue but personally if your dr says you need it and

you

know what you want...give us a little credit knowing what is best for us.

One size surgery does not fit all!!!!

hang in there...I never got anything approved but Ihave Regence and they are

HORRIBLE and if I could I would switch in a heartbeat or move where the DS

is

covered. However...since I love my house and where I live...I just shelled

out the money figuring I was worth the investment. I'm now working on what

my

next step is to begin pushing for changes. I don't know about the rest of

the country but in my area DSHS and Medicare have been coverage than I

do....LOL

I hope you win...and get something done with your insurance. I'll be

rooting

for you !!!

~*~ AJ ~*~

Age 37 5'8''

Post op 7/24/01 Open BPD/DS

self pay - Dr Baltasar -Alcoy Spain

07/24/01 BMI 64 415.1

08/06/01 BMI 59 390.2 -24.9 lbs!

08/16/01 BMI 58 387.0 -27.9 lbs!

08/24/01 BMI 58 386.5 -28.6 lbs!