Kaiser So. Sacramento frustration

[Diana S.]

I met with a surgeon at a California Kaiser Bariatric Center on December 1st, 2016. My interactions with him have been very disheartening. I do not believe he is taking my health care seriously, and is ignoring my specific needs to put off my medically necessary health care.

The surgeon conceded that bariatric revision surgery was in fact, medically necessary for me, but he has not taken into consideration my individual situation, specifically that I have already had a Vertical Sleeve Gastrectomy procedure performed, and as a result eat very little as it is. I am within the parameters of the pre-op diet already, though I redoubled my efforts to separate types of food and exercise on a daily basis. However, my caloric intake has always been between 1000-1200 calories per day, and so the pre-op diet that's supposed to make me lose weight prior to continuing on to other pre-op testing is a doomed goal I will never be able to achieve. Based on the surgeon's comments, he does not appear to care that I have excruciating co-morbidities that I have to suffer on a daily basis and this procedure is my light at the end of the tunnel to resolve these issues (either partially or totally), however it's being hung up by an unattainable goal that he is unwilling to discuss.

He has also made some incredibly worrying statements regarding the way human anatomy works. He has said several things that demonstrate an enormous lack of knowledge with the way my previous surgery works, the surgery he recommends (RNY) and the surgery I am requesting (DS), and how each of those factors influences weight loss and gain. When I mentioned the Duodenal Switch procedure, and was explaining why I was interested in learning more, the surgeon literally cut me off mid-sentence to say that DS is ONLY for patients with a BMI of over *60* and then proceeded to tell me blown-way-out-of-proportion horror stories about the DS. When I was trying to talk to him about how I am not losing weight on the 1200 calorie diet, because I already eat within those parameters, he said, "If you think you are [not] loosing weight by sticking to 1200 calorie diet and exercise then you will not loose weight with surgery also" which is just plain ignorant. If my VSG was sufficient, I wouldn't be back for the malabsorptive component to the surgery. I am also 11 years out from my VSG, so my body has more than adapted to the reduced intake, which is something he should know inside and out considering he is posing as a bariatric expert for Kaiser Permanente.

Based on my interactions with the surgeon, he either believes that I am a liar based on a very short consultation and some emails, and zero evidence that I have been anything but wholly honest (for indeed it is in my best interest to be honest with my health care providers), he has negative preconceived notions about the demographic of people struggling with their weight, or he's working from a boiler-plate flow chart that lacks any room for personalized care; something that Kaiser Permanente commercials tout very loudly but the surgeon is failing to demonstrate.

Admin note: Edited so that it could stay posted and not give away any surgeon name.

 

[DianaCox]

1) You have the right to request another surgeon.
2) You have the right to file a complaint against this MoFo for being disrespectful.
3) You have the right to demand that he give you a denial so you can appeal to the DMHC and stop screwing you over and killing you an inch at a time.

The fact is, there is no way Kaiser is going to refer you to Rabkin (out of network, which Kaiser HATES to have to pay for), without being ordered to by the DMHC. Stop trying to appease them - demand a denial so you can just move on to appeal to the organization which will overturn their bogus denial. There is NO valid BMI of 60 requirement - even NorCal Kaiser WILL refer someone with a BMI of 50 to Rabkin IF they know enough to request a DS. The DS is a standard of care procedure for essentially anyone who qualifies for bariatric surgery.

 

[Diana S.]

1) You have the right to request another surgeon.
2) You have the right to file a complaint against this MoFo for being disrespectful.
3) You have the right to demand that he give you a denial so you can appeal to the DMHC and stop screwing you over and killing you an inch at a time.

The fact is, there is no way Kaiser is going to refer you to Rabkin (out of network, which Kaiser HATES to have to pay for), without being ordered to by the DMHC. Stop trying to appease them - demand a denial so you can just move on to appeal to the organization which will overturn their bogus denial. There is NO valid BMI of 60 requirement - even NorCal Kaiser WILL refer someone with a BMI of 50 to Rabkin IF they know enough to request a DS. The DS is a standard of care procedure for essentially anyone who qualifies for bariatric surgery.

I am so freaking done with this super-rude jerk-face. I was going to wait until I had my psych eval to do this, but I can't deal with this idiot standing in the way for inane reasons and with complete ignorance for one more second. I just sent this in today:

"While I value your opinion, I have done extensive research on both RNY gastric bypass and the Duodenal Switch, and I am convinced that the DS is the best option for me. With the RNY, I would not be able to take NSAIDs any longer, would have the possiblility of marginal ulcers at the stoma punched into the stomach lining, and it has an unfavorable long-term outcome when compared to the DS. Meanwhile, there is no data suggesting that people BMI of < 50 do any worse than >50, most of the stages of the DS have been performed already (gastric sleeve, gall bladder removal), the DS has excellent long term results, maintains natural structures (pyloric valve).

I am requesting authorization for revision to the Duodenal Switch rather than the RNY gastric bypass. I am aware that surgeons in the Kaiser network do not offer the DS, and so I request authorization for the DS with Dr. John Rabkin of Pacific Laparascopy in San Francisco. I'm aware that Kaiser already contracts with him and his office."

Thank you Diana, for your support. If I didn't have access to the information I do through these forums, and you and Larra and others more knowledgeable and experienced than myself, I would be totally lost and stuck and disheartened. You make a world of difference!

 

[Larra]

Good job on the email. This is a clear request for authorization for revision to the DS. If you get a denial, which seems very likely, you will know where you stand and you can begin the process of appeals. If you get some kind of vague or noncommittal response, put in your request clearly a second time, and if still no definite yes or no, send a third email stating that you consider his lack of response a constructive denial and you are going to start the appeals process. @DianaCox can explain constructive denial better than I can, I have learned this term from her.

 

[SheenaM]

I was wondering if there was any update to this? I had my RNY in 2008, I only lost 50lbs, Ive since had two babies (who are now 4 & 3) and my stomach is always hurting like I'm hungry. It's all physical, even water hurts. Ive been in contact with Richmond bariatrics for 2 years, pushing for them to do an exam or something. They insist it is me, it's mental. I did 3 6 week boot camps, meal prepped and stuck to plan and lost nearly nothing! My metabolism is shot. Ive asked for a revision and they just want me to go to support groups or take Pepcid. I'll do classes if it helps me to get to my goal, but after 1 year post op, I never heard from bariatrics again!

 

[DianaCox]

I will let Diana S. comment when she sees this thread, but let me say this - THERE IS NO APPEASING KAISER! Don't wait for it to happen, even if someone else got approved - they will put EVERYONE through hell. But you're not going to get anywhere without starting the process.

Just get an appointment with your PCP, ask for a referral to bariatrics, and demand a revision to a DS, and specifically a referral to Dr. Rabkin, because you know they don't do revisions, much less RNY to DS revisions. They will deny you (tell them you KNOW they will deny you, and demand the denial in writing), but you have to go through it. We will have some additional helpful information for you once you are denied.

 

[SheenaM]

Do i need another referral to bariatrics if i already had my rny at kaiser Richmond and they’re still in charge of my post op?

 

[DianaCox]

You need an appointment with bariatrics to request the revision. If you can get an appointment at this point without a referral, then do it that way.

 

[SheenaM]

They will only set me up an appointment with a dietician. Bariatrics is refusing to do anything else except a dietician and support group. Which I’m happy to do both but it’s physical pain not mental

 

[DianaCox]

If they refuse to set you up wit an appointment to see a surgeon to discuss a revision, that sounds like a constructive denial. You should fave able to file an appeal now. But if would get it in the record that you specifically requested an appointment with a surgeon that was denied.

 

[Diana S.]

This entire last year has been 1. Ask for what I need 2. Get denied 3. File appeal with Kaiser 4. Get officially denied.

When you get to a certain point once you are officially denied by Kaiser, you file an appeal with the Department of Managed Health Care and go through the Independent Medical Review process. In my experience, the IMR came out against me because I didn't have an evaluation that no one expected me to have to get, even though I qualified for the DS and once I had that test they would see it as medically necessary. Now I finally have that eval and it looks like another 1, 2, 3, 4 process of which I've done 1, 2 and 3. I'm just waiting on the official "go pound sand" from Kaiser and then I can file a new IMR that will tell Kaiser in no uncertain terms to provide me with the services requested. Hopefully.

The only thing is... DON'T GIVE UP. This is a long process and I either get pissy or overwhelmed, but it keeps me fighting. The lesson I keep learning the hard way is not to give into your emotions and to never ever give them anything to use against you. SUPER EASY to type here and to say, but doing it for my own self has been a challenge :/

 

[Melli]

I was recently denied in Northern California I just received my paperwork for my IMR Complaint I'm so afraid of being denied again and having to look for a surgeon out of the country because I'll have to pay out of pocket I had surgery in 2009 Gastric bypass my surgeon told the most I would lose is 40 pounds he was right I was type 2 and I have PCOS and I have problems using the bathroom and I'm sure I have acid reflux and heart burn I'm requesting full blood work amount other things Kaiser methods to getting help you need are a headache I'm even thinking of changing my health coverage other hospitals don't put you through the hassle

 

[Diana S.]

From what I understand all insurance companies will put you through about the same ringer, and they all hope you give up and go to another plan because statistically we do after three years. BUT Kaiser has been nothing but unhelpful along my journey. They Kaiser dietitian didn’t even know anything about the DS and her whole report was heavily biased.

My advice, when you file your IMR, make sure you include a Letter of Medical Necessity from your chosen surgeon (Dr. Rabkin and Matt from his office are ANGELS), a psych eval and a dietary eval (that covers your detailed understanding of the procedure and the potential for deficiencies and your “anticipated compliance” to taking your supplements and following the DS-lifestyle). If you’re missing any of those, the IMR reviewer will deny you like they did me. I’m in my third IMR now and I could have saved MONTHS if I had this all ahead of time.

I got all these evals from trusted, unbiased, outside sources, so there may be a need to go through an appeals process with Kaiser for example: asking for a psych eval if they’re blocking you, getting denied by them and then getting your own (I forget the terminology, something like your fully vested appeal rights). Others will be able to clarify that for you.

But make sure you have all the pieces when you file your IMR, they threw a curve ball at me with the dietary eval and will probably require it from now on :/

Feel free to PM me if you’d like to talk off the record... I try to keep my expletives off forums even though I’ve blown up out of sheer frustration a few times 0_0

 

[southernlady]

I try to keep my expletives off forums even though I’ve blown up out of sheer frustration a few times 0_0

No need to...I don't have cuss words blocked. I do have stuff blocked that spammers like to use which is why pharmaceutical names come up on that list.

 

[Diana S.]

No need to...I don't have cuss words blocked. I do have stuff blocked that spammers like to use which is why pharmaceutical names come up on that list.

Mostly it's in regards to badmouthing the people I've had the displeasure of speaking to along my way... and having the possibility of the wrong person finding my rants and putting them in my medical file (or something like that) as a black mark against me... like "watch out for this one, she's an unreasonable, unstable so-and-so!"

That being said, I have encountered a STAGGERING amount of ignorance and ineptitude along the way from my health plan. I wouldn't let any of the bariatric team I've met come NEAR me with a scalpel... I wouldn't have any faith in the outcome.