Ok second attempt to post!!! IM SO MADD!! What would you do?

[Guest guest]

Ok Im almost violent Im so upset. If I owned an ozzie I might unload

it on FUTURE HOUSE AND NORTH BAY HEALTH PARTNERS!! I am almost dizzy

from all of the changes today. Ok I am venting, but Im also asking

for each of your thoughts and guidance. I want to know what you

would do in my situation. This isn't a short post so please forgive

me but its necessary in order to really help you understand the

problem.

History: RNY in April 04. Dr. Rabkin SF, open laparotomy to fix a

perforated bowel May 04, June 04 open laparotomy due to bowel

obstruction, internal bleeding and adhesions. All done by the same

doctor (Perforation was done by a gastroenterologist NOT my

surgeon). Lose my job because Im off work too long. Lose my

insurance carrier August 31st 04. Get new job in August, get new

insurance North Bay Health Partners effective Sept 1st. WHEW! Ok but

they don't actually get my policy started until the end of

September. since then they have sent me NO information about my

policy. I dont know whats covered and what isn't. I find out 2 days

ago that I have an EPO..an employed peferred provider program. Never

heard of it before now, but its just like a PPO. Bad news for me it

seems.

So first I get a call from the docs office today asking if they can

move my surgery to Wednesday because the OR didn't get enough time

booked for my surgery if they are goig to do the tummy tuck too.

Well I decided even if I have to pay the $4500 for it myself, its

getting done at the same time because I don't want anymore surgery!

Wednesday works better for me anyway because I could use the extra 2

days of work before hand to get my patients in order before I go

(and the income!). I had the wrong hospital down..my surgery is NOT

at Cal Pacific..its at St. 's in San Francisco...an IN Network

hospital. She also tells me that they haven't gotten the approval

for my surgery yet and there is a concern because my surgeon is out

of network. OH GREAT!! So sometime after lunch today, I get a call...

Surgery has been DENIED completely! Because my surgeon is out of

network!!!! They say they will pay but only if I go to an IN NETWORK

doctor! Ok Im pissed from that moment on. I call the insurance

company and they tell me to go to my in network primary care doctor.

I tell the lady..I dont have one. She is shocked! Says you havent

got an in network primary doc? Im like NO. I then remind her Ive

only had this insurance for 2 months and I didn't even know I had

this rule in my policy. She says well it should be listed in the

information " we send you " . Excuse me? What INFORMATION! I haven't

gotten a thing..I reply. She says oh. YA OH! So she goes on..

well you need to go to an in network primary care doctor and get a

referral for the surgery first, then get to an in network surgeon

and be evaluated and then have them submit and we should be able to

cover it. Im like...Lady do you have any idea what you are saying to

me? I DON'T HAVE THE LUXURY OF TIME HERE! I HAVENT BEEN EATING SOLID

FOODS FOR WEEKS, AND IVE BEEN IN ER 5 TIMES ALREADY!!!! This is a

complication from a surgery 9 months ago and Dr. Rabkin IS my

doctor. You didn't tell me this a month ago or have problems with

the fact that he had me in the hospital. Why am I hearing about this

now? What more do you want me to do? She says, Im sorry we can't

help you, you need to go to an in network doctor and hangs up.

I call Human resources crying (all this while in a patients home

watching her IV drip very slowly and realizing that I have no choice

but to take care of it then because they will be closing in a few

hours for the holiday weekend). I tell the lady in charge of dealing

with our insurance company whats going on. She can't believe it,

says she is going to call and find out what she can do to help!

She calls back about 1/2 hr later and says, you just need to go to a

different surgeon. LIKE DUH!!! She does say tho that the issue is

that its been labeled urgent, but not EMERGENT. So I say, ok so your

telling me that if I go to ER in pain, and they contact Dr Rabkin,

and he takes me to surgery because its emergent, THEN THEY PAY? She

says Yes. I say..Ok great thats what I will do. She says what? I

said, ok well I will just go to ER and have them take me to surgery

from there! She says ok but you didn't hear that from me!!

So I call back my surgeon. Talk to the insurance lady again there

who has been going back and forth between us, and tell her..Look Im

going to show up at ER bright and early Wednesday morning with pain

(which is no big surprise since i haev it all the time now). Expect

a call. Because that is the only way they will pay for this, is if I

go through ER first. She calls the surgeon who says, they still may

not get paid. MY REPLY! THEN I WILL PAY YOU!!!! DAYUM! JUST GET THIS

DAMN THING DONE!!!

So..Im now paying out of pocket for my tummy tuck..fine expected to

do that anyway, the hernia repair is OUT, because it is very small,

and frankly Im not paying an extra $3000 in surgeons fees for it at

the moment, and Im going to pay for my open exploratory laparotomy

IF they deny me later. Hopefully the surgeon will accept from me

what the insurance company would have paid..which is about another

$1100.

What would you all do in my situation? I figure if they refuse to

pay for it, I will just get my father involved. He is an attorney

and does insurance law also. In the meantime, that gets me into

surgery and hopefully gets me better! What do you think my chances

are of actually getting all this done? It really sucks having

nothing in stone. But this is my life we are talking about..and as a

single mother I dont have the luxury of letting this go any longer

and getting weaker and weaker while they run me from doc to doc.

Kat