Re: Judi In Miss/ Insurance Approval

[Guest guest]

Jeannie .... can you tell me about your experience with OPM? I have written to them for a liaison to help me get the surgery -- how did they go against you? what was the process? Can I call you and talk about all this? Or call me ...?

Judi in MS

Awaiting Ins Approval

Dr. Booth

BMI 59

[Guest guest]

Jeannie .... can you tell me about your experience with OPM? I have written to them for a liaison to help me get the surgery -- how did they go against you? what was the process? Can I call you and talk about all this? Or call me ...?

Judi in MS

Awaiting Ins Approval

Dr. Booth

BMI 59

[Guest guest]

> Jeannie .... can you tell me about your experience with OPM? I

have written

> to them for a liaison to help me get the surgery -- how did they go

against

> you? what was the process? Can I call you and talk about all

this? Or call

> me ...?

>

> Judi in MS

> Awaiting Ins Approval

> Dr. Booth

> BMI 59

Judi,

I am not at home so I don't have your number right now. I lost with

OPM because there was no contract violation. My HMO didn't want to

send me out of network. My appeal was based on the fact that no one

in network could do the duodenal switch. My HMO said that since my

goal was weight loss, there was no significant medical difference

with the results for weight loss between the RNY which I could have

done in Network and the Duodenal Switch which would have to be done

outside of their network.

OPM sent all the information that I sent them, and trust me it was a

lot, to an independent medical doctor who agreed with the HMO which

is why I lost the appeal.

Jeannie

Let me see if I can find someone for you to call at BC/BS if so I

will post it for you today.

[Guest guest]

--

Judi,

I know this sounds crazy but I think the lady was right. I found out

from the casemanager that I had spoken to that every BC/BS is

different. With Federal BC/BS you precertify (although that isn't

what they call it) with whatever area doctor you are seeing. They

then turn around and bill your local BC/BS. There isn't any

" preauthorization " with BC/BS but you do have to have your hospital

stay precertified. It's really confusing. Anyhow, that may be why

they told you to have it done elsewhere. It's easier to get approved

that way even if it is stupid stupid stupid. Good Luck

- In duodenalswitchegroups, MistyEve@a... wrote:

> Jeannie,

>

> I spent the better part of today on the phone, with my BCBS of

MS appeals

> coordinator (who told me I should go have the procedure in CA and

have them

> bill BCBS of CA!) but who had no answer as to what the review board

says

> about my appeal of the first denial. I also talked with Dr Booths

nurse tech

> - who told me she would be spending the afternoon on my case

- and when

> I told her about what BC said -- was speechless. BC told me the

contract is

> federal - but that means nothing if your local plan won't accept

what your

> doc sends in as the procedure. I know I could probably get the rny

accepted

> - even here -- but I can't figure a way around them for the DS.

> I even went so far as to call CA docs. I called Dr Anthones

office -

> tried explaining what my BC people said -- woman there thought she

had no

> idea what she was talking about - cause the MS BSC lady said I did

not even

> need prior approval for this surgery. Anyway - Dr A has no

openings for

> consults until July - heck - I could be dead by then. I also

called Dr

> Kerschian (sp?) in Delano - since they seemed so helpful online to

someone

> elses request .. but they never returned my call. I am feeling

desperate and

> confused. I am not sure where to turn or what to wait for or what

to do

> next. Sorry about the whining here ...

> Judi

>

> Judi in MS

> Awaiting Ins Approval

> Dr. Booth

> BMI 59

[Guest guest]

--

Judi,

I know this sounds crazy but I think the lady was right. I found out

from the casemanager that I had spoken to that every BC/BS is

different. With Federal BC/BS you precertify (although that isn't

what they call it) with whatever area doctor you are seeing. They

then turn around and bill your local BC/BS. There isn't any

" preauthorization " with BC/BS but you do have to have your hospital

stay precertified. It's really confusing. Anyhow, that may be why

they told you to have it done elsewhere. It's easier to get approved

that way even if it is stupid stupid stupid. Good Luck

- In duodenalswitchegroups, MistyEve@a... wrote:

> Jeannie,

>

> I spent the better part of today on the phone, with my BCBS of

MS appeals

> coordinator (who told me I should go have the procedure in CA and

have them

> bill BCBS of CA!) but who had no answer as to what the review board

says

> about my appeal of the first denial. I also talked with Dr Booths

nurse tech

> - who told me she would be spending the afternoon on my case

- and when

> I told her about what BC said -- was speechless. BC told me the

contract is

> federal - but that means nothing if your local plan won't accept

what your

> doc sends in as the procedure. I know I could probably get the rny

accepted

> - even here -- but I can't figure a way around them for the DS.

> I even went so far as to call CA docs. I called Dr Anthones

office -

> tried explaining what my BC people said -- woman there thought she

had no

> idea what she was talking about - cause the MS BSC lady said I did

not even

> need prior approval for this surgery. Anyway - Dr A has no

openings for

> consults until July - heck - I could be dead by then. I also

called Dr

> Kerschian (sp?) in Delano - since they seemed so helpful online to

someone

> elses request .. but they never returned my call. I am feeling

desperate and

> confused. I am not sure where to turn or what to wait for or what

to do

> next. Sorry about the whining here ...

> Judi

>

> Judi in MS

> Awaiting Ins Approval

> Dr. Booth

> BMI 59