Crap band removal approved but DS denied.... Help!

[Amey]

That was my next question... Do you know of any doctors within 4 hours that does the DS? I have an appt for a phone consultation with Cottam on the 22nd. I emailed the insurance coordinator and said that under no circumstances should anything further happen with the appeal until I personally talk to Cottam and get the sleep study results. I told her I wanted a phone call returned and if I didn't get a returned call after 3 days of leaving messages that I would assume they no longer want my business and will look elsewhere..... Which I'm now regretting because there isn't an elsewhere within a reasonable distance.

That's really discouraging about the 2 doctors coming in to Blackfoot. I really had my hopes up for them.

I will call St Luke's and see what I can find in Dr Oakley. Boise isn't any further than Salt Lake. I'll let you know what what I find out. Thanks for the help.

 

[southernlady]

@Amey how far is Dr. K from you? http://www.dssurgery.com/locations.php?subnav=4 or Dr. Rabkin? http://www.paclap.com/pacific-laparoscopy/locations.cfm Even if either one is over a 4 hour drive, I would do travel.

 

[Larra]

Diana has given you much more info that anyone else ever could have, but I will add to this that it is time for you to start thoroughly documenting everything - every single contact with any surgeons, their office staff, and of course with your insurer. Keep all emails and snail mails, and keep a record of every phone conversation with date, time, name of person you speak with and job title, their phone number, and a summary of the conversation.
Also, request your medical records. The stuff from the orthopedist about joints may be helpful in documenting arthritis in your weight bearing joints, the sleep study of course, anything else that might justify medical necessity for your revision.

And, if it turns out that these 2 new surgeons actually do the DS (seems unlikely at this point but who knows what they are planning), and you end up consulting with one or both of them, ask about how a serious complication would be dealt with at this small hospital, is there a contingency plan for transfer to a more well equipped hospital, that sort of thing.

If you do end up going through appeals, writing appeals letters, etc, let us see/edit whatever you write before you send it in, and if at all possible get your hands on whatever LOMN (letter of medical necessity) your surgeon writes BEFORE it gets sent anywhere. You can then send it to us (we of course can't get it directly from your doctor) and we can make sure it says what it needs to say and recommend changes if needed. Hopefully your surgeon, whoever it may be, would be open to recommendations.

 

[Amey]

Amey,

I talked with your insurance company and I am faxing back to them Dr. Cottam's history and physical where I have circled the reason's Dr. Cottam states the band needs to come out. This was sent in with the original paperwork, however your insurance stated "we could have missed that originally" so asked I fax it to them again, which I have done. Also I received your message that Jason from the Counseling Center was going to call the insurance and give them his information as well, so I passed that message on to your insurance as well.

Thanks,

Paula

BMI

Dear Amey,


I am very sorry we have not done enough to satisfy your needs. We communicate with you nearly daily and it is not enough for you. Our advice is to get the band out and then pursue obtaining another weight loss surgery in the near future. You obviously do not agree with the authorization experience we see every day with your specific situation. We have stated it is rare for insurance to approve a band removal and change to another weight loss procedure at the same time. The proof is you have already obtained approval for the removal and denial for an additional weight loss procedure. It is not very likely that your insurance will come back and approve both procedures without you meeting their original requirements.


Is it possible that if you show more health problems associated with your weight to get this approved? Yes, but rare. In fact peer to peer has less of a chance of getting approval over taking the time to follow the insurances entire requirements for weight loss surgery after you get the band removed.


I am sorry to state it so bluntly but that is reality. Since you are unwilling to trust our experience in these matters we feel it would be best if you take your services elsewhere. You may want to look into the University of Utah’s program or programs in Boise. You can have them utilize the same approval with your insurance for the band removal.


I will make sure Dr. Cottam sees this email so he knows what is going on.


We wish you all the best,


Darren



Darren J. Cluff, MPA | Practice Administrator

Bariatric Medicine Institute | 1046 E 100 S | Salt Lake City, UT 84102

801-869-7110 Office Direct | 801-869-7130 Fax Direct to my

The document and content in this email may contain confidential health information that is privileged and legally protected from disclosure by federal law, the Health Insurance Portability and Accountability Act (HIPAA). This information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, copying, acting upon or otherwise using the information contained in this email is strictly prohibited. If you have received this information in error, please notify the sender immediately.


From: Paula Larsen
Sent: Friday, July 17, 2015 8:06 AM
To: Amey Nelson
Cc: Darren Cluff
Subject: RE: Insurance


Amey,


I am not in the office today, but able to access my email. I HAVE NOT started an appeal or any peer to peer review yet because I was told you were getting a sleep study test done and I wanted to wait, as per your instructions, for those results before any of this was put in place. So again I have not started either of those yet.


I will copy Darren on this email so that he can respond to the rest of your concerns.


Paula

Bariatric Medicine Institute


From: Amey Nelson

Sent: Thursday, July 16, 2015 4:23 PM
To: Paula Larsen
Subject: Re: Insurance



Please call me asap!!! I have realized that the consent papers Dr Cottam had me sign say LOOP DS. I DO NOT WANT A LOOP DS!!! I just want the STANDARD DS with a commom channel of no more than 125 cm and preferably 100 cm. The insurance submission was for a standard DS but my paperwork says otherwise. I'm confused! What do I need to do to rescind my consent for Loop DS and sign consent for regular DS?

Also...I am having a sleep study done tonight to diagnose sleep apnea. You should be aware that it will take about 2 weeks to get those results.

Absolutely NO peer to peer consultation should take place until I have the correct paperwork signed and I have consulted with Dr Cottam... I have a phone consult scheduled for the 22nd. If Dr Cottam is not willing to do the surgery as a regular DS then there is no point in going forward with an appeal from your office and I will look for another surgeon to treat me. I need to hear this from Dr Cottam not from anyone else!! I have already contacted an attorney for consultation regarding my appeal.

I am extremely concerned by the lack of communication from BMI regarding the lack of returned phone calls and demanding that communication is only done via email. No other professional physician's office does this. Please call me on my cell phone 1st thing in the morning!! 208-680-1618. If I don't hear from you or Darrin then I will assume BMI does not want my business and I will look elsewhere for treatment.

Amey Nelson

On Jul 14, 2015 11:21 AM, "Amey Nelson" wrote:

Thank you so much.. I really appreciate your effort to get this done. I just talked to Jason, the counselor, and he said that when he talked to Blue Cross they told him that they just needed the clinic notes for medical necessity from you guys... Nothing from him. But he sent his notes again to be safe.I'm sure you hear it a thousand times a day but I'm just so tired of being sick and tired. Thank you again... I know you are really busy and this takes extra time away from your other tasks. Thank you!!

On Jul 14, 2015 10:42 AM, "Bariatric Medicine Institute" wrote:

Amey,

I talked with your insurance company and I am faxing back to them Dr. Cottam's history and physical where I have circled the reason's Dr. Cottam states the band needs to come out. This was sent in with the original paperwork, however your insurance stated "we could have missed that originally" so asked I fax it to them again, which I have done. Also I received your message that Jason from the Counseling Center was going to call the insurance and give them his information as well, so I passed that message on to your insurance as well.

Thanks,

Paula

BMI

I have left messages for you for over 3 days with no response. And still I just get emails and no phone calls. Why?

Yes I would like Dr Cottam to do my surgery. Revisions are done in the sane surgery all the time... It is not rare!!! My problem is not worth Dr Cottam's skill but with the professionalism of the office staff.

I have a phone consult scheduled with Dr Cottam in the 22nd. I need to hear from him what the plan is as I feel I am just getting turned in circles from the staff. Thank you for your time.

▶ Show quoted text

 

[Amey]

This is the email going back and forth with BMI. I think I they just fired me. Now what?

 

[Amey]

Dr K is a 2 hour flight from Salt Lake which is a 4 hr drive.

 

[southernlady]

Dr K is a 2 hour flight from Salt Lake which is a 4 hr drive.

Is it worth it??

We know of people who travel all over. My husband traveled to NYC from Tennessee. I know one member who traveled from South Africa to see Dr. K.

Getting a DS surgeon is so worth it.

 

[Amey]

Of course it is worth it. Unfortunately.... My bank account has other ideas. I couldn't afford the place tickets, hotel for a family member and me after the surgery and the time off from work that a trip to California would require. I'm feeling pretty lost. I just need to get my head wrapped around this, find out what kind of time frame I have for an appeal and go forward. I wish I could go to Dr K but unfortunately it's not feasible and I doubt he would be in my ins network.

 

[DianaCox]

Getting an experienced surgeon who will do a PROPER DS is worth it. And Drs. Keshishian and Rabkin are the best of the best. Your commute is a PITA, but this is your LIFE we are talking about.

Cottam's office staff (and to be honest, Cottam himself, insofar as his consent form is utterly misleading and he apparently made no effort to make sure you gave FULLY informed consent) are unprofessional and IMHO, unethical. You have the right to be upset, and they have an obligation to address your valid concerns professionally - they have not done so. I would in your position be angry, disappointed - and glad that I dodged a bullet BEFORE being subjected to a surgery you didn't want or knowingly consent to, with a practice that is unprofessional.

Time to contact Dr. K or Dr. R (Dr. K is more insurance-friendly), and arrange for travel. A year from now, you will be glad you made the financial and convenience sacrifices.

I hope the new surgeons moving to your area will be able to handle your follow up, and perhaps - assuming they intend to add the DS to their practice - you can be the veteran patient for their support groups, having the knowledge you glean from us.

 

[DianaCox]

Dr. K takes BCBS.

Um, what is the point of the appeal if Cottam (or Darren, his uppity "Practice Manager") has fired you?

 

[Larra]

Yes, I think you have been dumped. This may well turn out to be a blessing in disguise, though it will mean more travel for you. I think the time has come for you to accept the need for travel and sort out the logistics. Remember, the important thing is to get the care you need, because you will be living with the results of your decisions for the rest of your life. Logistics is just logistics, and extra inconvenience/unpleasantness of travel etc is temporary.
Our experience here is that it is not rare for people to have band removal and revision at the same time. Granted there are times when the band removal proves to be so difficult due to scar tissue or other problems that it must be done in 2 procedures, but there is no way to know this in advance (well, unless it is known, for example, that the band has eroded into the stomach or some other complication). And from what I can see, you do meet the qualifications for medical necessity for bariatric surgery, but you do need to provide your insurer with more documentation.
One suggestion I have would be, in future correspondence with this or any other surgeon's staff, to try for a more professional tone. Avoid all the exclamation points (!!) and use wording that indicates that you and they are a team, working together towards the same goal...even if it doesn't really feel that way. They don't need you, there is an endless supply of people needing bariatric surgery, and most of them will not be revisions and will be easier for both the surgeon (easier operation) and his staff (easier, routine insurance approval) to work with. So there is no incentive for them to go out of their way to help you.

Just thought of another option, keeping in mind that I don't know where you are or what travel locations are easiest from your location. Dr. Srikanth in Washington State has an excellent reputation as a DS surgeon and I'm sure he's done band to DS revisions. He's in Federal Way, WA , phone (253) 815-7774. Don't bother looking at Oregon, no one there.

 

[southernlady]

Okay, what about Dr. Simper? http://utahbariatrics.com/ It's worth a call to his office. I know @newanatomy had Dr. Simper.

 

[newanatomy]

I did have Dr. Simper and he does do revisions even though I was a virgin DS. He is located in Salt Lake. I would caution you to not come at his office quite as "hot" as with Dr. Cottam's office. I think most Dr.'s shit themselves when they learn you have "consulted with an attorney". They don't want "difficult" patients. I am not saying it is right, only that that is how it probably is.

I found Dr. Simper's office staff frustrating, irritating and downright annoying. They can be quite as "uppity" as the staff you encountered at the other office but, you will get more flies with honey. Also, just nod and bob with the nutritional information you get from Dr. Simper's staff, it will save you countless headaches. You need to relax a bit, be patient with the approval process. Dr. Simper is not a warm and fuzzy type. He is a good surgeon with a good reputation.

I have BC/BS Anthem, which he accepts. You will have to call the office to see if they accept your insurance.

http://www.utahbariatrics.com/

Rocky Mountain Associated Physicians
1160 E. 3900 S. Suite 4100 • Salt Lake City, Utah 84124
1.800.999.9970 • 1.801.268.3800

Good luck!

 

[Amey]

So here's the update. Dr Cottam's office and I have officially gone our separate ways. I called my insurance company. There is no time frame that I have to wait for another surgeon to start over with a fresh request for surgery. I let them know I would not be using Dr Cottam and would be looking for a new doctor. I do not have an exclusion that says only one bariatric surgery... It is all based on medical necessity. The lady I spoke with was very helpful and emailed me the provider's document that lists their criteria of medical necessity. It's basically BMI over 40 with a comorbidity that they would otherwise cover and could be treated with weight loss ie sleep apnea, diabetes, osteoarthritis, etc. I had a sleep study last night and I know I have arthritis in my knees that was documented 6 years ago but I'm going to go to a dr to getva fresh diagnosis for good measure.

I called Dr Simper's office and spoke to his MA and explained my situation. She spoke with the doctor and he agreed to see me for a consult. I will be receiving an email with paperwork to fill out on Monday. He is in network with my insurance.

So... Things are looking up. I'm breathing, I'm calmed down, I'm ok. I'm going to take the time to do this right and get my ducks in a row and document everything.

On a side note.... 3 other people on the FB group have realized as of today that Dr Cottam did the loop when they only consented to a standard DS. I have an angel watching out for me... There is something to be said for unanswered prayers.

 

[southernlady]

On a side note.... 3 other people on the FB group have realized as of today that Dr Cottam did the loop when they only consented to a standard DS. I have an angel watching out for me

And ONE of the three is lawyering up...apparently she works in the medical field and has a sister who is a lawyer.