FitN2007
July 7, 2005
I finally have my new insurance membership id number. It has been such an ordeal trying to just get to this point. For so long it felt like I was on the bench watching others play. Now I am finally at least on the team. Now the question is will I get to play. My friend and I (she is hoping to have the surgery too) called Kaiser last week and they said that with the Flex Choice Option you did not have to go through the 6 months of supervised diet with a nutritionist. I've learned in the past that the story changes depending on who you talk to so we will see. I just called Dr. B's office to get the approval process started. I was so scared my hand was shaking and my heart was pounding. I know I have to keep trying and being persistent but the thought of being rejected after so many months is unnerving. Pray for a positive and speedy answer! 
July 13, 2005
Now I begin to see.. I thought the approval process was well underway since I talked to the Dr's office on the 6th. In fact I stopped by the office Monday the 11th and was told that 'we haven't heard anything yet'. Today I found out (by accident) that it still has not been submitted - I don’t even have a case number with the insurance company. Apparently a phone call has to be made to Health International so they can set up a case number, then it goes to the triage nurse and it is at that point that the pre-determination letter and clinicals are submitted. So I called the Drs office again to see what was happening and the same person said she knew I didn't have a case number yet because she hadn't called them yet!, and that it would be done this week. Then she asked me for the number if I had it handy. She acted like she knew about the process all along - which is probably true but then why didn't she tell me earlier this week that it hadn't been done instead of saying that she was still waiting to hear back from the insurance company. I know that the Dr’s office is down one staff member and they have a lot of patients but it is a frustrating because my life is in the hands of others. There is nothing I can do but push from the outside. I am used to making things happen - especially if they are important to me. I am not used to depending on others. Just trying to breathe and have faith that spirit will make this happen.
One piece of bad news was that when they had another patient with the same type of insurance (Kaiser with Flexible Choice Option) they had to go through the 6 month nutritionist crap. This makes no sense to me since my nutritional needs after the surgery will be completely different as will the amount of food I can intake. I have made a decision that is best for me, now it has to be judged by others. Augh! Breathing, breathing, breathing.
July 14, 2005
Got a call from Dr's office and they are working on it. I have a case number and they are waiting to hear back from the triage nurse re the paperwork needed. Yeah! Still up in the air about the 6 months. They don't think so but I am not going to get my hopes up yet.
I joined a gym at the begining of July. It's been great. I really love going. I do water aerobics, cardio boxing, pilates and yoga classes. They also have a great sauna and steam room. I get 2 free sessions with a trainer to work out a routine on the weight and cardio machines. I love this gym.
Fingers crossed and breating.
July 18
"What we have here is a failure to communicate." I can't remember the movie that comes from but that about sums up what is happening with my insurance company. Just to recap: kaiser (KP) contracts with Health International to administer the Private Health Care Services (PHCS) network available to Kaiser members. Ok, even though I talked to three people at Kaiser before switching and was told that as long as it was med necessary WLS would be approved - apparently no one at KP told the people at Health International! Since they administer the PHCS part of Kaiser - or the Tier 2 PPO - they are the ones who grant preauthorization for surgery. Unfortunately after an hour on the phone with the surgeon's office, and an hour on the phone with Kaiser (with me on hold on the other end) their computer still says that WLS is excluded!! What!? The folks at KP don't know where Health International got that information? There is no information at KP that says it is excluded so why do they think that Kaiser told them it is excluded... SO now the woman who wrote the contract (the Plan Manager at KP) with Health International is pulling out the original to review it. Man.
The up side is it is covered@! The question is do I have to go through the 6 months pre certification stuff and have a Kaiser surgeon or not. I was hoping to hear definitavely today by 5pm but no word. Hopefully tomorrow morning.
tune in tomorrow for the next segment of "whose on first"
July 22, 2005
After pulling the original contract it was found that Kaiser does cover WLS for their HMO, and PPO patients in both Tier 2 and 3. Yippeeee! The approval is handeled through Health International. So I get off the phone with Kaiser, after hearing this good news, and excitedly call the surgeons office to share news with them and M. tells me that she just - JUST - got off the phone with Health International and was told that they have nothing to do with the approval of WLS!!! Huh?? So I get back on the phone with Kaiser member services (thanks so much Richard and Sally), and yes HI does approve WLS, they just don't know that they do~~~ a situation which will be rectified shortly!!! Apparently there are several issues that HI is suppose to be handeling that they aren't handling. This is really a matter of the this being a new partnership between Kaiser and Health International. These are the bugs! Frustrating but fixable. Still breathing.
July 27, 2005
A lot has happened - and nothing has happened - since I last posted. So far I have seen my pulmonologist and the cardiologist - everything is fine. However, my PCP suspects that I may have bladder cancer. Even typing the word scares me. Somehow if I give it voice, it will be real. I have been to a urologist and although he says that at my age it is unlikely, the fact that I smoked a pack a day for almost 20 years does double my risk for developing bladder cancer. Most people don't develop this type of cancer until they are in their 70s however. I am trying to hold onto that idea but in the meantime they are running all these tests and little by little I am starting to realize that all, and I mean ALL, these tests are looking for cancer. My mother always said if you look hard enough for something you will find it.
I love my PCP, she is great. However, she does tend to start at the top of the food chain, in terms of disease, and work her way down. In other words she has started by ruling out bladder cancer instead of ruling out a garden variety UTI - or even a serious bladder infection. And, of all the symptoms of bladder cancer, one of which is unexplained weight loss (HA!) I only have one. But the one I have is a classic symptom. I have a background in health and I am a researcher by nature and profession, not to mention the fact that I work at a cancer organization, so I am not the type of patient who will just blindly have tests without looking into them. That is both good and bad. I am trying to breathe. I am trying to be present and not rehearse anxiety needlessly. However, I am plain old, unadulterated scared. The type of scared where I can't catch my breath. If you are reading my profile please say a prayer to Ja, Jesus, God, Yawhew, (sp?), Oshun, the Orisha, or any other diety you happen to believe in. I think deep down inside I know that cancer is not my journey...but what if Im wrong.
Nothing is happening in terms of WLS. Dr. A's office moved last Friday and when I called them on Tuesday they said that they hadn't even unpacked the phones or the files yet. Therefore nothing has been done with my approval. I have tried to be patient but I know that I will have to call them tomorrow and get them to push Health International. How much you wanna bet that they haven't done that since they unpacked the phones.....
October, 10, 2005
It has been a long frustrating summer. After 2 months of the run around by Kaiser, I was told that I could not have the surgery through Flex Choice - only through the tier 1 HMO. Customer services suggested I write a pre-service appeal, which I did. I outlined all the mixed messages that I've gotten from different people. And they started their review - which took a month. During that time I contacted the Obesity Law Group and they submitted a letter as well. Suddenly I got a call the very next day. They said all I had to do was call provider services and request a referral for bari surgery. I did, they set me up with a nurse to review my case and it was immediately forwarded to a physician to review. Yes, I thought finally I am home free. It took 4 months and here I was - close. Then today they called and it was denied. I was told to request an expedited appeal - which was denied too (the expedited part). Now I have to have a face to face meeting with them. The reason for the denial - no 6 months of diet. Since I knew this at the begining why did they tell me to request the referral. So it is back to th lawyer.
