ampt
WWBD? What would bacon do?
Hi all. I’m newly approved and SCHEDULED (*queue singing angels*). My DH and I are doing this TOGETHER. Our DS journeys are VERY different. His BMI was over 50, so Kaiser outsourced his DS to Dr. Rabkin in San Francisco, CA. I had to FIGHT for mine (BMI below 50, by 18 pounds). Here is my saga in a (large) nutshell:
July 26th: Kaiser WLS Intro Seminar
August 11th: Fremont Kaiser Bariatric Orientation
August 23rd: my first appointment with my WLS surgeon. No mention of DS. My DH's appt was same day, later, different surgeon. DH was told about DS because his BMI is over 50. He mentioned the DS to me as an option later that evening. He started doing research. Before long, I was convinced, especially since it would mean that we would have the same surgery and the same post-op lifestyle.
August 30th: phone appt with my surgeon to discuss DS, he was NOT for it, too dangerous, malnutrition, high-risk surgery
September 17th: Sent in Kaiser appeal to get out of network referral for Dr. Rabkin
October 18th: Kaiser appeal denied; "not medically indicated"
October 29th: Requested my medical records from Kaiser to check up on my record
October 31st: Consult with Dr. Rabkin (same day as my husbands, who had a referral); paid for mine out of pocket to get a letter of medical necessity from Dr. Rabkin to strengthen my IMR case to DMHC
November 15th: Faxed IMR to DMHC
December 17th: Received letter of qualification from DHMC (32 days later)
December 30th: Received copy of Kaiser’s letter sent to DHMC: no psych eval, no nut eval, not completeing “several clinical items” as recommended by Dr. Rabkin.
January 2nd: Faxed rebuttal letter and materials to DHMC to prove that Kaiser had misinformed the DHMC about my meeting with a nutritionist, and them denying me a psych evaluation because I did not meet their ± 10% weight loss prerequisite, ALSO, my BMI was listed as 45 when it was 48.
January 10th: IMR denial. DS was not clinically indicated “AT THIS TIME.” Clearly, the reviewer disregarded evidence in my file and then cited the absence of that evidence as a reason for upholding the denial (ludicrous), and the reviewer did not answer the question whether the DS was appropriate for me with a BMI <50. (Nearly 60 days after my IMR was sent in!!)
January 16th: Talked to compliance manager at DMHC, he said that once I met with nutritionist (already done) and had psych evaluation, I could apply for a re-review WITH KAISER, and if denied AGAIN, I could re-apply for another IMR.
January 16th: I sent in another complaint to Kaiser Member Services that I was never given a denial for the psych evaluation in writing (DMHC no-no)
January 17th: After my advocate talking to the compliance manager’s supervisor, he assured me (us) that he would look over my case, and get back to us to see if he could help. I gathered all of my documentation and my advocate sent a STRONGLY worded letter.
January 24th: DHMC contact got back to me (us) to say he was going to confer with DMHC attorneys regarding reviewer’s language in IMR denial.
January 27th: Diagnosed with moderate sleep apnea
January 29th: Talked to Kaiser Member Services about getting denial in writing. Fremont Bariatric told her that I was never actually denied but that I did not meet the requirements for such an appointment (same thing, right?) Also, received an official letter from Kaiser Member Services saying they would get me a resolution in 30 days (already 13 days after I submitted the complaint)
January 30th: DMHC contact communicated that 1) IMR reviewer did not endorse Kaiser’s position that DS was too risky, so presuming basis for denial was overcome. 2) Reviewer said “not clinically indicated at this time” because of psych eval and nut eval, SO once I have those done, he would bring it to Kaiser’s attention.
January 31st: Sent in additional documentation of Kaiser’s “10% prerequisite weight loss” to DMHC contact.
February 4th: Psych evaluation with Dr. Bill Hartman (paid out-of-pocket)
February 10th: received glowing psych eval (“I’m not crazy! My mother had me tested!”); Forwarded to DMHC contact.
February 11th: DMHC contact had spoken with Kaiser, and they were reviewing my situation.
February 13th: DMHC contact spoke with Kaiser. They didn’t want to accept” my out-of-network psych eval. They wanted one of their staff to perform the evaluation which they would schedule right away. I agreed to this, just to try to get my approval done faster!! DHMC contact also said Kaiser admitted that nobody has to go through any pre-op classes or weight loss, etc. just the nut and psych evals, which they are NOT to deny, and if they are being forced to do so in the future, he was to be contacted directly.
February 14th: Received letter from Kaiser Member Services saying the psych evaluation is a pre-op requirement and in order to get that requirement finished I needed to lose the prerequisite weight; something about needing to have a “consistent process” for the patients.
February 14th: No call from Kaiser to set up psych eval because they reconsidered their position and were putting together my AUTORIZATION PAPERWORK!
February 19th: Approval for consultation (already had October 31st); in turn, Dr. Rabkin’s report sent right back to Kaiser to start process for surgery approval.
March 3rd: Call from Outside Referrals “handler” to tell me that she cannot approve me for surgery until all my pre-op testing is done (chest x-ray, echocardiogram (because of my sleep apnea), EKG, PCP physical and lab work) and PCP issues clearance.
March 4th: PCP physical, lab work, chest x-ray
March 6th: echocardiogram, EKG; PCP emailed me later in the day to tell me all results were normal.
March 7th: Left message for Outside Referrals that all testing was complete, and PCP put in letter to clear me for surgery. BTW, she doesn’t work Fridays!
March 10th: Left ANOTHER message for Outside referrals; was called back shortly after to say she had all of the components, and would be forwarding the surgery authorization to Dr. Rabkin’s office in the next couple of days.
March 13th: Outside Referrals had contacted Dr. Rabkin’s office and said there was an issue with something in the authorization paperwork, but that it was alright to go ahead and schedule the surgery; tentatively scheduled for May 15th pending Dr. Rabkin’s approval.
March 17th: LUCK O’ THE IRISH! Surgery confirmed for May 13th!!
Again, I could not have done it without DianaCox and Larra -- Hundreds of emails (literally!), tough love, patience, encouragement. They were instrumental in getting my appeal granted, and surgery approved. I'm here to PAY IT FORWARD.
July 26th: Kaiser WLS Intro Seminar
August 11th: Fremont Kaiser Bariatric Orientation
August 23rd: my first appointment with my WLS surgeon. No mention of DS. My DH's appt was same day, later, different surgeon. DH was told about DS because his BMI is over 50. He mentioned the DS to me as an option later that evening. He started doing research. Before long, I was convinced, especially since it would mean that we would have the same surgery and the same post-op lifestyle.
August 30th: phone appt with my surgeon to discuss DS, he was NOT for it, too dangerous, malnutrition, high-risk surgery
September 17th: Sent in Kaiser appeal to get out of network referral for Dr. Rabkin
October 18th: Kaiser appeal denied; "not medically indicated"
October 29th: Requested my medical records from Kaiser to check up on my record
October 31st: Consult with Dr. Rabkin (same day as my husbands, who had a referral); paid for mine out of pocket to get a letter of medical necessity from Dr. Rabkin to strengthen my IMR case to DMHC
November 15th: Faxed IMR to DMHC
December 17th: Received letter of qualification from DHMC (32 days later)
December 30th: Received copy of Kaiser’s letter sent to DHMC: no psych eval, no nut eval, not completeing “several clinical items” as recommended by Dr. Rabkin.
January 2nd: Faxed rebuttal letter and materials to DHMC to prove that Kaiser had misinformed the DHMC about my meeting with a nutritionist, and them denying me a psych evaluation because I did not meet their ± 10% weight loss prerequisite, ALSO, my BMI was listed as 45 when it was 48.
January 10th: IMR denial. DS was not clinically indicated “AT THIS TIME.” Clearly, the reviewer disregarded evidence in my file and then cited the absence of that evidence as a reason for upholding the denial (ludicrous), and the reviewer did not answer the question whether the DS was appropriate for me with a BMI <50. (Nearly 60 days after my IMR was sent in!!)
January 16th: Talked to compliance manager at DMHC, he said that once I met with nutritionist (already done) and had psych evaluation, I could apply for a re-review WITH KAISER, and if denied AGAIN, I could re-apply for another IMR.
January 16th: I sent in another complaint to Kaiser Member Services that I was never given a denial for the psych evaluation in writing (DMHC no-no)
January 17th: After my advocate talking to the compliance manager’s supervisor, he assured me (us) that he would look over my case, and get back to us to see if he could help. I gathered all of my documentation and my advocate sent a STRONGLY worded letter.
January 24th: DHMC contact got back to me (us) to say he was going to confer with DMHC attorneys regarding reviewer’s language in IMR denial.
January 27th: Diagnosed with moderate sleep apnea
January 29th: Talked to Kaiser Member Services about getting denial in writing. Fremont Bariatric told her that I was never actually denied but that I did not meet the requirements for such an appointment (same thing, right?) Also, received an official letter from Kaiser Member Services saying they would get me a resolution in 30 days (already 13 days after I submitted the complaint)
January 30th: DMHC contact communicated that 1) IMR reviewer did not endorse Kaiser’s position that DS was too risky, so presuming basis for denial was overcome. 2) Reviewer said “not clinically indicated at this time” because of psych eval and nut eval, SO once I have those done, he would bring it to Kaiser’s attention.
January 31st: Sent in additional documentation of Kaiser’s “10% prerequisite weight loss” to DMHC contact.
February 4th: Psych evaluation with Dr. Bill Hartman (paid out-of-pocket)
February 10th: received glowing psych eval (“I’m not crazy! My mother had me tested!”); Forwarded to DMHC contact.
February 11th: DMHC contact had spoken with Kaiser, and they were reviewing my situation.
February 13th: DMHC contact spoke with Kaiser. They didn’t want to accept” my out-of-network psych eval. They wanted one of their staff to perform the evaluation which they would schedule right away. I agreed to this, just to try to get my approval done faster!! DHMC contact also said Kaiser admitted that nobody has to go through any pre-op classes or weight loss, etc. just the nut and psych evals, which they are NOT to deny, and if they are being forced to do so in the future, he was to be contacted directly.
February 14th: Received letter from Kaiser Member Services saying the psych evaluation is a pre-op requirement and in order to get that requirement finished I needed to lose the prerequisite weight; something about needing to have a “consistent process” for the patients.
February 14th: No call from Kaiser to set up psych eval because they reconsidered their position and were putting together my AUTORIZATION PAPERWORK!
February 19th: Approval for consultation (already had October 31st); in turn, Dr. Rabkin’s report sent right back to Kaiser to start process for surgery approval.
March 3rd: Call from Outside Referrals “handler” to tell me that she cannot approve me for surgery until all my pre-op testing is done (chest x-ray, echocardiogram (because of my sleep apnea), EKG, PCP physical and lab work) and PCP issues clearance.
March 4th: PCP physical, lab work, chest x-ray
March 6th: echocardiogram, EKG; PCP emailed me later in the day to tell me all results were normal.
March 7th: Left message for Outside Referrals that all testing was complete, and PCP put in letter to clear me for surgery. BTW, she doesn’t work Fridays!
March 10th: Left ANOTHER message for Outside referrals; was called back shortly after to say she had all of the components, and would be forwarding the surgery authorization to Dr. Rabkin’s office in the next couple of days.
March 13th: Outside Referrals had contacted Dr. Rabkin’s office and said there was an issue with something in the authorization paperwork, but that it was alright to go ahead and schedule the surgery; tentatively scheduled for May 15th pending Dr. Rabkin’s approval.
March 17th: LUCK O’ THE IRISH! Surgery confirmed for May 13th!!
Again, I could not have done it without DianaCox and Larra -- Hundreds of emails (literally!), tough love, patience, encouragement. They were instrumental in getting my appeal granted, and surgery approved. I'm here to PAY IT FORWARD.
:Mess:
