Uggh! Huge Mistake. Bariatric office prematurely sent in my info for pre-determination.

[irishmom1972]

I'm a bit perturbed right now. Since I completed the bariatric program checklist, I called to touch base with the bariatric surgeon's coordinator this morning to ask her to get the information sent in to BCBS asap for DS Surgery approval. Since I don't fit BCBS IL's minimum BMI requirement of 50 (just a few pounds off), I wanted her to add some other points that would strengthen my case. I just learned that the coordinator already submitted all my information for a pre-determination for DS last week. She didn't consult me first. I had no idea that she already sent in my info to my insurance company. The main battle that I'll most likely have with the insurance is that I don't meet the BMI requirements. I'm 20 lbs away. The coordinator used a recent weight that was from last week when I met the surgeon to specifically discuss DS and I was a few pounds lighter. At my very first consultation with the surgeon back in August, I was heavier and that's the weight that the were supposed to use to submit to insurance (I've been trying to change my habits now pre-surgery and lost a couple pounds since that initial consultation). The coordinator also submitted a height that was 1" taller than I actually am (which slims me down even more).

She said she's going to follow up on Friday with BCBS, but the information she submitted was weak, inaccurate, and she had a very careless attitude when I brought up my concerns of the incorrect weight/height that she submitted. I told her that my insurance might change as of Jan. 1st and that I needed information to be submitted correctly and thoroughly. She sounded very apathetic. She said that if I end up getting repeatedly denied for DS Surgery that I'll just have to choose another surgery if I'm under pressure to get it done by the end of the year. She nonchalantly gave me an example of how one man was denied because he didn't meet the BMI, so he chose RNY instead....like he was choosing between which flavor of ice cream. I had no idea that she was just going to submit the information without talking to me first. She's always so hard to get a hold of too. Wow. This is probably an indication of how they'd treat me post-op. Careless. Geeze, if I was a coordinator and knew how much a certain surgery meant to a patient (she knew because I had a previous conversation with her), I would get the information straight before submitting it to insurance, and I'd be more compassionate with the patient. This office is like an assembly line though...stacks and stacks of patients to get through the assembly line. I'm just another number. Wish I could talk to the surgeon and give him a piece of my mind about how this was handled. One in a million chance that I'll get approved this go-around.

Tomorrow I have a consultation with Dr. Prachand's office at U of C to discuss DS Surgery. The coordinator there who handles insurance is much more thorough and takes more time with you. However, I wish that pre-determination request wasn't sent in by Dr. Kane's office already.

 

[Clematis]

I'm sorry. I know how difficult this is. Sometimes they make it seem like they are doing you a tremendous favor in performing a medically necessary procedure. But I see no reason why Prachand's office can;t submit documentation as well and that set will be the correct height and weight. Good luck

 

[Munchkin]

Well, all you can do now is wait! I agree there are too many medical providers who are just apathetic and don't care. It's just another day at the office for them, but it's your life!

 

[Larra]

I've been following your saga and this is truly unfortunate. However, if I understand everything correctly, you are talking about the coordinator with Dr. Kane or the Kane clinic or whatever them call themselves, right? This group is not known for doing the DS. In fact, I had never heard of him or them before you started posting here. So clearly this isn't their regular operation of choice and if you get stuck with something that isn't what you want/need it's all the same to them. You're just one more body on the conveyor belt.
I don't blame you at all for being upset about how you are being treated, but perhaps this will turn into a blessing in disguise in that it will get you to commit to having surgery elsewhere. Dr. Prachand and co. have a solid reputation. I am hopeful that, if you get an accurate height and weight and emphasize the medical concerns that point you towards the DS rather than any other operation, he will be sympathetic. At least you have a better shot at it with him than with whoever the hell you are working with now.
And you are absolutely right - if this is how you are being treated pre-op, you will be even less of a priority as a post-op. Get out of there. You deserve better.

 

[DianaCox]

Assholes. Get out of there. And FAX a letter to your insurance company immediately, telling them that (1) you are withdrawing your request for pre-certification; (2) that you are withdrawing it because there are GLARING errors in the information that was submitted; (3) that you are withdrawing it because you believe you have made a mistake in selecting a surgeon who is apparently not looking out for your best interests, and whose office staff is less competent than you require for your health care.

Larra may disagree with the last two - but I'd be hopping mad and would want it on the record that ERRONEOUS AND FALSE information was submitted by the doctor's office, so I was not having to explain it again when resubmitting with a better practice.

 

[Larra]

Well actually, I sort of agree with @DianaCox on this one and I think she has given you some great advice about contacting the insurance company yourself instread of letting this stand. I personally would not use the word "glaring" in saying that there are errors in their submission, but that's me. And While I would tell the insurance company that I am not using this surgeon and his staff, I wouldn't say the stuff about them being incompetent and so on. Just that you are going elsewhere for your medical care.
Do what is comfortable for you.

 

[irishmom1972]

So after I learned about the Kane centers insurance coordinator botching up the pre certification and sending it prematurely to Blue Cross Blue Shield, I had an appointment yesterday for the first time with Dr Prachand's office at the University of Chicago. I spent 3 hours there meeting the nurse, psychologist, dietician, and then Dr Prachand. Their scale was 10 lbs lighter than my home scale. I was 304 lbs at home yesterday morning and their scale said 294!!! So according to them, my BMI is 46 which is even lighter than what the Kane Center's coordinator submitted to the insurance without my knowledge. So I'm feeling like my insurance battle with their BMI requirements has gone from bad to worse.

BTW, Dr. Prachand said that duodenal switch wouldn't be his first choice for me because there's no data on the long-term success for my sized patients (BMI 's 40-50). I mentioned that I don't want gastric bypass because I want a full functioning stomach and I want my pyloric valve intact. I gave him a list of why I am choosing duodenal switch over gastric bypass. He explained that a lot of the unsuccessful gastric bypass patients that you hear about today were not properly taught Pre-surgery 10-20 years ago. After I told him about my NSAID requirement, he started talking about sleeve. He said there is a group of patients that have the sleeve gastrectomy who are super responders, and they lose 100% of their excess body weight. I don't want to bank on that kind of super response for me, because I've had a lot of stalls during my recent dieting attempts and my metabolism is shot. Again, I told him that I really need the malabsorption. He then went into the risks of duodenal surgery, down the line with all the male nutrition and vitamin deficiencies. In the end, he said that he's willing to do the duodenal switch surgery on me, but I'm not typically the patient demographic that he does them on. His team will meet next week and discuss me, and I'll hear back from them in a couple weeks. I'm also supposed to hear back from the Kane center either on Friday or on Monday with an answer to the half assed pre-certification that they sent in for the duodenal switch surgery with Blue Cross Blue Shield Illinois. I'm not even sure if I should make a call to BCBS at this point.

 

[Larra]

OK, Dr. Prachand isn't thrilled about you having a DS, but it sounds like he'll do it because you showed him some good reasons and that you know what you would be getting yourself into. And I agree with you completely that while there are some patients who do great with a sleeve, there is absolutely no guarantee that you will be a super responder. So stick to your guns with him and his group and I think you will have found your surgeon.

Regarding the pre-cert that has already been submitted, I must re-emphasize @DianaCox 's advice to call and get that thing withdrawn. There is no benefit to you in having a denial before you even get off the ground. You don't have to give them reasons or diss the idiot who sent it in. If they want a reason, you can just say that you have switched surgeons, which is nothing but the truth. They really don't care what you think of the prior surgeon and even less about his office staff. So just get it withdrawn and leave it at that.

 

[irishmom1972]

@Larra and @DianaCox . This whole thing is messed up. After months of visiting four different bariatric surgeons and even completing one bariatric program's entire prerequisite checklist with the pulmonologist, sleep studies, psych evals, abdominal ulrasounds, nutrition classes, dieticians, etc., I feel like I'm starting from scratch now.

On Friday, I called BCBS and the agent said the pre-determination had already been with the review team for over a week and at that point, it was probably fruitless to try to retract it. They made a notation on my record that I called. Regardless, the BMI that the careless insurance rep at the Kane Center submitted was near the same BMI that U of C recorded me at last Wednesday when I had my initial consultation with Dr. Prachand. Dr. Prachand is not really on my side either because DS isn't his first choice of surgery for me. His first choice was RNY for me. After I told him some reasons why I couldn't have RNY (I need NSAIDs and don't want that amount of dumping, etc.), he started pushing sleeve gastrectomy. In the end, he told me that he'd consider doing DS on me, but it wouldn't be his first choice because of all the vitamin deficiencies long term and possible malnutrition. He said that he and his team would discuss me next week and I will be hearing back from them within a couple weeks. If Dr. Prachand thinks that DS isn't a good first choice WLS for me, then I don't think he and his office will be on my side when fighting the insurance. What should I do now? Can't fight the BMI anymore....it is what it is and has been recorded at two different offices.

 

[DSRIGGS]

@Larra and @DianaCox . This whole thing is messed up. After months of visiting four different bariatric surgeons and even completing one bariatric program's entire prerequisite checklist with the pulmonologist, sleep studies, psych evals, abdominal ulrasounds, nutrition classes, dieticians, etc., I feel like I'm starting from scratch now.

On Friday, I called BCBS and the agent said the pre-determination had already been with the review team for over a week and at that point, it was probably fruitless to try to retract it. They made a notation on my record that I called. Regardless, the BMI that the careless insurance rep at the Kane Center submitted was near the same BMI that U of C recorded me at last Wednesday when I had my initial consultation with Dr. Prachand. Dr. Prachand is not really on my side either because DS isn't his first choice of surgery for me. His first choice was RNY for me. After I told him some reasons why I couldn't have RNY (I need NSAIDs and don't want that amount of dumping, etc.), he started pushing sleeve gastrectomy. In the end, he told me that he'd consider doing DS on me, but it wouldn't be his first choice because of all the vitamin deficiencies long term and possible malnutrition. He said that he and his team would discuss me next week and I will be hearing back from them within a couple weeks. If Dr. Prachand thinks that DS isn't a good first choice WLS for me, then I don't think he and his office will be on my side when fighting the insurance. What should I do now? Can't fight the BMI anymore....it is what it is and has been recorded at two different offices.

Dr Prachand is supposedly the guy who taught my original DS surgeon how to do the DS. Dr Marshall tries to push people away from the DS as well, but he does it as a weeding out tactic (my opinion only) because he wants people to prove that they have done their homework and are committed to the requirements of the DS. What Prachand is doing sounds like the same thing.

Stick with it, show him that you have done your homework and why THE DS IS THE ONLY BARIATRIC SURGERY for you.

It will work out in the end and if you have to travel for the surgery I know for a fact that BCBS is accepted by Dr Keshishian and that he and his staff would advocate for you strongly. Hopefully Prachand and company can get you approved (keep pushing like Larra and Diana have said, they know their stuff when it comes to denials and approvals) but if they can't don't give up hope as there are other options.

 

[irishmom1972]

I'm wondering if I should even go to a third bariatric office, Dr. Inman in Indiana...four hours from me which is difficult when I have six small children. Tell her straight out that I'm being denied by BCBS IL becuase of a BMI less than 50. She if she could help out in any way. Or just stick with Prachand?

 

[DSRIGGS]

I suggest playing this out with prachant. I was approved with 46 BMI.. I think. May have been 43 and I am BCBS administered in IL.

 

[Larra]

Don't give up on Dr. Prachand. Even if the DS isn't his first choice for you, it sounds like he is at least willing to consider it for you. He's an experienced DS surgeon and with all those children it would be great if you could get your surgery relatively close to home. If he just doesn't work out, do try with Dr. Inman. The travel element will be more difficult but if you put your mind to it and hopefully can recruit some assistance, you can make it happen. Start with the assumption that there IS a way to do it, then figure out what the way is, rather than the assumption that it can't be done.

 

[irishmom1972]

@Larra and @DSRIGGS and @DianaCox .... more important insurance questions. Our 2015 plan ends Dec. 31. Supposedly, we are having the same level of coverage next year only more expensive premiums and deductibles. If I start an appeal right process right now, can it drag on beyond Dec. 31, 2015 into 2016? Or, does everything start over on 2016, including my deductibles, out of pocket max, BCBS's new terms (if any) for WLS, etc. In other words, if this appeal process drags on & on, once Jan. 1, 2016 starts, we will still be under the same terms as we are right now or does everything start from scratch and new coverage applies?

 

[DSRIGGS]

@Larra and @DSRIGGS and @DianaCox .... more important insurance questions. Our 2015 plan ends Dec. 31. Supposedly, we are having the same level of coverage next year only more expensive premiums and deductibles. If I start an appeal right process right now, can it drag on beyond Dec. 31, 2015 into 2016? Or, does everything start over on 2016, including my deductibles, out of pocket max, BCBS's new terms (if any) for WLS, etc. In other words, if this appeal process drags on & on, once Jan. 1, 2016 starts, we will still be under the same terms as we are right now or does everything start from scratch and new coverage applies?

Not an insurance expert but unless the plan itself is changing that shouldn't matter. If co-pays go up you will of course pay the copay that is in place when services are rendered, but increased premium and copay should have nothing to do with approval as long as the policy coverages haven't changed.