Any DS surgeons in California or Utah who accept Medicaid?

[ShmittyInVegas]

Daily Digest (pardon the pun):

Surgeons insurance coordinator: "Medicaid generally covers these procedures if we prove medical necessity. The only problem is that Nevada Medicaid won’t usually cover any procedures done in Idaho.".

Me: Even if we claim it to be necessary?

Surgeons insurance coordinator: "You may be able to talk to them and see if they’d make an exception to have it done in Idaho, they would have to approve it and be willing to pay the hospital here."

I called medicaid to ask for an EOC for both Amerigroup Medicaid and Health Plan of Nevada Medicaid but she didn't have a clue. I then asked for a supervisor but she said that there wasn't one there I can speak to. She directed me to dhcfp dot nv dot gov

 

[DianaCox]

OK, now you need to call the Dept of Insurance in NV, and tell them you have a RIGHT to receive the contract information that relates to your insurance coverage.

 

[ShmittyInVegas]

OK, now you need to call the Dept of Insurance in NV, and tell them you have a RIGHT to receive the contract information that relates to your insurance coverage.

. The same would apply even to a Medicaid hmo?

 

[Spiky Bugger]

. The same would apply even to a Medicaid hmo?

It says you can find it here...

How can I comment on rate increase requests by insurers?
Rate filings and plans are available for your comments on the Division of Insurance website. A brief explanation of the rate request will accompany each filing and the plan documents including the Schedule of Benefits and Evidence of Coverage will also be available for review. All comments will be reviewed and made public if you so desire.


...which I found here:

http://doi.nv.gov/Health-Rate-Review/FAQs/

 

[ShmittyInVegas]

Where on the page did you find the ECO? "Nevada Mandated Benefits"?

 

[Spiky Bugger]

I didn't look for it. Given that THEIR website says it will be available, I'd just make phone calls. I usually start by finding their info someplace like Yahoo Financial, get the name of the head of their legal department (look under "officers" and "inside traders"), find a press release and call THAT office (the PR people almost always list a phone number on press releases) and ask them to transfer me to the legal department person's (by then I can ask by name) office. Sounds tedious, but it's actually faster than dicking around with customer service.

Then I'd just say that "I believe" they are required to provide me access to a copy of the EoC...and yet no one on their Customer Service side knows how to make that happen. And...while filing a complaint with the state seems excessive for such a simple request for something the have a legal requirement to provide...it may be my only option if you folks cannot help me acquire that document. (Yeah...I'm a bitch...but I'm good with that....it's the remainer of the world`s population that seems to have trouble with it.)

Sometimes...I share a teeny bit of info with the PR people...like, "I'm trying to avoid filing a complaint with the state." They are the ones who have to cover for screw ups, so they may try to help you.

 

[Clematis]

As a marketing consultant. I can attest that the marketing (or PR) department knows everything about their company and can sort out in minutes what it can take months for customer service.

 

[ShmittyInVegas]

Got some good news today. Medicaid will be switching my coverage from Amerigroup to Health Plan of Nevada, which covers the duodenal switch (I think?).

 

[DianaCox]

"which covers the duodenal switch (I think?)"

If you don't KNOW, why did you change?

 

[ShmittyInVegas]

This is under their "Commercial Care Rationale:"

"The following bariatric surgical procedures are medically necessary in adults for the treatment of clinically severe obesity as defined by the National Heart Lung and Blood Institute (NHLBI): • Gastric bypass (Roux-en-Y; gastrojejunal anastomosis) • Adjustable gastric banding (laparoscopic adjustable silicone gastric banding) – See FDA section/information • Gastric sleeve procedure (also known as laparoscopic vertical gastrectomy or laparoscopic sleeve gastrectomy) Bariatric Surgery.doc Page 2 of 42 • Vertical banded gastroplasty (gastric banding; gastric stapling) • Biliopancreatic bypass (Scopinaro procedure) • Biliopancreatic diversion with duodenal switch"

Found this in the "Medicare Coverage Rationale:"

"Bariatric Surgery for the Treatment of Morbid Obesity (NCD100.1) Nationally Covered Indications Effective for services performed on and after February 21, 2006, Open and laparoscopic Roux-en-Y gastric bypass (RYGBP), open and laparoscopic Biliopancreatic Diversion with Duodenal Switch (BPD/DS), or Gastric Reduction Deuodenal Swithch (BPD/GRDS), and laparoscopic adjustable gastric banding (LAGB) are covered for Medicare beneficiaries who have a body-mass index > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. Effective for dates of service on and after February 21, 2006, these procedures are only covered when performed at facilities that are: (1) certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006). Effective for dates of service on and after September 24, 2013, facilities are no longer required to be certified."

But under the "Medicaid Coverage Rationale" all I could find was this:

"Bariatric Surgery is a covered Nevada Medicaid benefit reserved for recipients with severe and resistant morbid obesity in whom efforts at medically supervised weight reduction therapy have failed and who are disabled from the complications of obesity. Morbid obesity is defined by Nevada Medicaid as those recipients whose Body Mass Index (BMI) is 35 or greater, and who have significant disabling comorbidity conditions which are the result of the obesity or are aggravated by the obesity. Assessment of obesity includes BMI, waist circumference, and recipient risk factors, including family history. This benefit includes the initial work-up, the surgical procedure and routine post surgical follow-up care"

 

[DSRIGGS]

Got some good news today. Medicaid will be switching my coverage from Amerigroup to Health Plan of Nevada, which covers the duodenal switch (I think?).

Great news, I think.

 

[DianaCox]

Any news?

 

[ShmittyInVegas]

I still haven't heard back frmo the folks up in Idaho. Meanwhile I have been getting all of my exams done down here and passsed my psych eval.

 

[DianaCox]

Great - keep at it. Call them politely every day.

 

[Amey]

Dr Medvetz in Idaho is who I am going to go have my DS done. However she has never done it by herself before. She was supposed to have a proctor, Dr Bonnani from PA here this week to proctor 3 DS's (she has to have 6 proctored to go it alone). Those surgeries were post-poned until the end of February. I don't know the reason they were delayed other than In guessing they want all 6 in the same week and are trying to round up a few more. I know one person that was scheduled for the 29th....that's how I know this. I was scheduled for the 28th but due to insurance complications mine has been delayed until I file another appeal and see how that goes... But this appeal will take a couple months. Dr Medvetz is a good surgeon..... But it seems they are having a hard time getting enough DS surgeries scheduled in the same week for the proctor to make it worth his time to fly across the country. Good luck!