Different Authorizations?

Diana S.

Well-Known Member
Joined
Nov 21, 2016
Messages
80
Location
Georgetown, CA
Does anyone have any experience between the timely authorization I received for an apparent consultation and the actual authorization for surgery timeline?

My surgeon's office received the auth for a *consultation* from Kaiser today, and he will send them the info from the consultation I had forever ago asap, but said it may take MONTHS to get the actual auth for *surgery*...

I have the direct line for the person I can bug, but has anyone had experience with this, and is it truly an expectation of months that I have to wrap my head around?
 
You’ve already had (and self-paid) for the consult, and received a leg letter of medical necessity from Rabkin, which was reviewed by the DMHC THREE FRICKIN’ TIMES and surgery was approved! You need to call Kaiser and tell them to change that to a preauthorization for SURGERY and then immediately call your contact at the DMHC and tell them what Kaiser is trying to pull, and ask him to escalate it to DMHC legal immediately! This is BULLSHIT!

In the meantime, since Kaiser has acknowledged that they have to pay for at least the portion of the appeal directed to the consult with Rabkin, which they also denied, immediately submit your invoice from Rabkin for the consult for reimbursement.
 
You’ve already had (and self-paid) for the consult, and received a leg letter of medical necessity from Rabkin, which was reviewed by the DMHC THREE FRICKIN’ TIMES and surgery was approved! You need to call Kaiser and tell them to change that to a preauthorization for SURGERY and then immediately call your contact at the DMHC and tell them what Kaiser is trying to pull, and ask him to escalate it to DMHC legal immediately! This is BULLSHIT!

In the meantime, since Kaiser has acknowledged that they have to pay for at least the portion of the appeal directed to the consult with Rabkin, which they also denied, immediately submit your invoice from Rabkin for the consult for reimbursement.

I will do that, but I also got a call from Liz who did the authorization and she said that she can’t send the surgery authorization until I get more lab work and any pre-surgical tests that Dr. Rabkin wants... is this standard procedure or is this also moot and she needs to just authorize the surgery already?
 
I'm not certain, but I'm pretty sure she's got this in the wrong order. You need authorization for SURGERY with Rabkin (which, by the way, is what the DMHC ORDERED them to give), and I suppose that Kaiser can require the routine lab tests, EKG and chest X-ray to be done ON RABKIN'S ORDER by Kaiser.

But you can't get those tests done until you are on Rabkin's surgical schedule, because these tests need to be done within a certain amount of time pre-op, and you can't get on his schedule until you have the AUTHORIZATION from Kaiser.
 
I think @DianaCox has it right. Hopefully this is just some confusion by an employee who isn't used to doing these, and who doesn't understand that you already had the consult, but let the DMHC know what's going on regardless, and persist until you get the right authorization (i. e. for the surgery itself, then all the appropriate labs and other pre-op tests can be done in the right time frame).
 
Also, after years of dealing indirectly with her, Liz is apparently tasked (or takes it upon herself to do so) with making your referrals and scheduling with outside providers as difficult as possible. DO NOT TRUST HER AT ALL!
 
Well I called Liz back and explained that my IMR approval was for the surgery and I needed to get on the schedule etc and she called me back and boy does she know how to make me feel stupid. Said this is the way it’s always been and that there’s no relation to these tests and the timing of the surgery.

Called and left a message for my DMHC contact explaining and asking for advice.

Meanwhile I’m gonna contact my Kaiser PCP and ask for these tests to get that ball rolling sooner than later.
 
Read the DMHC decision again carefully. Kaiser was REQUIRED to authorize the services within FIVE WORKING DAYS in the letter dated January 9th. They are already in violation. The services covered were DS procedure with hiatal hernia repair - NOT JUST THE CONSULT!!
 

Latest posts

Back
Top