Need Help getting approved! !!!

[Glam]

Today I found out from my insurance that bcuz my surgeon is non par they wont approve my surgery. However they have approved my request for a referral & EGD with the same surgeon. My question is this: how is it possible that the insurance approved 2x already now when it's time for surgery they say he's non par. Which he's always been non par! This is really frustrating bcuz I've wasted 5 months of my time. If anyone have any insight I'd greatly appreciate it. I'm on Humana through Medicaid in FL.

Edited to add my surgeon is willing to accept insurance. The hospital is in-network

 

[Munchkin]

Who is your prospective surgeon?

 

[DianaCox]

Ask your doctor's office if they can talk to Humana to become in-network for your procedure. Alternatively, you can call your Medicaid ombudsman and ask for help. But - WHO IS YOUR SURGEON?! There is NOBODY in FL I would be comfortable with, and you might want to SERIOUSLY consider trying to go out of state.

 

[Glam]

@DianaCox please don't crucify me......but it's Dr Hoddinott. I've read all of the things that has happened with him. I have researched him intensively. I've met some of his DS patients all of which are doing great.

 

[DianaCox]

Somebody find Larissa's story for her.

Hoddinott is not only non-par, he's sub-par. WAY sub-par.

 

[Munchkin]

RUN!

 

[Glam]

I hear both of you. I talked to Medical Director of the bariatric team at Humana. They said I can request a expedited hearing to get a waiver to go to a out of network provider stating there's no doctors in network for the DS. If I get a waiver I can go to one of the vetted DS surgeons. Can you offer me some tips for my request of a out of network waiver please?

 

[DianaCox]

You need to be able to state that there are no doctors qualified to safely perform a DS on you, due to your special circumstances. That is going to probably involve presenting evidence that:

1. Dr. Hoddinott has a history of malpractice claims and poor outcomes with his prior DS practice; he stopped doing them for a long time due to concerns about his skills and poor outcomes; he has only performed X number of DSs in the last 5 years (get that number from him personally); he does not have an adequate track record with people who are super super super morbidly obese like you are.
2. You might want to find out whether the hospital he operates at has facilities for patients your size, including bariatric beds and operating tables, laparoscopy equipment that can be used on someone your size, open MRI available onsite.
3. Dr. Jawad has very little experience or expertise in performing routine DSs on patients who are merely morbidly obese, much less people who are super super super morbidly obese like you are.
4. Same questions about Jawad's hospital.
5. Then find the corresponding information about a surgeon and his facility who WILL agree to operate on you, and his facility - if not Smith, perhaps Sudan at Duke in NC?

That way, you can show that although there are surgeons in FL who CLAIM to do the DS, they are not qualified to perform it on such a high-risk patient as you. You don't want to end up with a subpar surgery, a half-surgery, or no surgery at all, due to their lack of expertise in dealing with a patient of your size and medical history.

 

[Munchkin]

Listen to Diana! She knows what she is talking about!

 

[Glam]

Thx to everyone that has replied to my post.

@DianaCox my Bmi is only 44. I think you have me confused with another that posted about seeing Dr Hoddinott too. I need to appeal & ask for a waiver to see a out of network provider, reasoning being there's no provider in network that performs the DS. Today I had the head nurse of Humana bariatric team tell me ....I'm paraphrasing. ....to have either the lap band, sleeve or bypass. I replied that to me it was a violation of my rights. According to my policy I'm entitled to 4 procedures. ...I chose the DS......it seems to me a take it or leave deal.

She's talking to the Medical Director again on my behalf but she did tell me be prepared to appeal for a out of network provider.

 

[southernlady]

@Glam, I was on my third appeal to go out of state for the DS when I lucked up and was able to go with Dr. Boyce (in state but since I actually started with his partner, Williams had to release me first).

What *I* did was contact EVERY single bariatric practice in state...most did not even DO the DS (which I already knew), the ones that did were either out of network or refused to do the DS on a lightweight. Since my insurance had no problem approving the DS but wanted me to stay IN state, I had to do all that legwork. Literally Dr. Boyce was the LAST one I contacted cause of his partner. Williams, altho can do the DS, would NOT consider anyone under a 50 BMI even tho he KNEW I needed NSAIDS. His response was, well, just take narcotics for the pain...not no but HELL NO!

 

[DianaCox]

Thx to everyone that has replied to my post.

@DianaCox my Bmi is only 44. I think you have me confused with another that posted about seeing Dr Hoddinott too. I need to appeal & ask for a waiver to see a out of network provider, reasoning being there's no provider in network that performs the DS. Today I had the head nurse of Humana bariatric team tell me ....I'm paraphrasing. ....to have either the lap band, sleeve or bypass. I replied that to me it was a violation of my rights. According to my policy I'm entitled to 4 procedures. ...I chose the DS......it seems to me a take it or leave deal.

She's talking to the Medical Director again on my behalf but she did tell me be prepared to appeal for a out of network provider.

Oops - yes, I did get you confused (I thought you were her posting under a different name, since the stories seemed superficially similar) - sorry about that. Essentially the same situation - except perhaps DON'T tell them that you know of someone who does the DS in-state - they may not keep track of these things. Call 4 or 5 nearby surgeons who you know DON'T do the DS, and document that they told you they don't, and then ask to be sent out of state. Tell them that you are on a DS support group who said there were no qualified DS surgeons in Florida. If they don't know about Hoddinott allegedly being a DS surgeon, don't tell them!

 

[Glam]

I really want to thank you for your help. I called again to ask for a waiver w/o having to file a appeal. But if I have to I think I have enough information that you all have provided. Thx again. ......wish me luck.....lol