HELP - I NEED YOUR ADVICE !!!! I just got denied for surgery because of my doctor's notes (insurance only good for another 100 days)

[marketingdude 79]

Lapband Talk Members:

I'll try to condense the situation as much as I can. The following are the facts with my (about to retire & skinny) filipino doctor and my 6 Month Diet Program. Although I didn't know this beforehand, I found out that my doctor has a prideful attitude about weightloss thinking you can do anything if you put your mind through ect....even though he knows my families history of obesity and my brothers successful lapband surgery where he was 429 lbs and now down to 160lbs.

* 12/14/10 - 1ST DOCTOR VISIT - given phentermine to help with weight loss (Weighed in at 284lbs at 5'9)

* 1/18/11 - wife works for the state and we now have lapband coverage through our insurance.

* 2/1/11 - found out that the lap band is covered through our health insurance with a 6 month weight assistant diet plan

* 2/23/11 -2ND DOCTOR VISIT (lossed 6 pounds - now at 278) TOLD DOCTOR ABOUT HOW I WANT THE LABPAND PROCEDURE and how my insurance will cover it with a 6 month diet program. Told him the insurance company will take the 6 month diet program and make it retroactive when I first started seeing him back in December. I originally wanted to go with him because he is familiar with my families obesity (we lived right behind him growing up) and HE KNOWS ABOUT MY BROTHERS SUCCESSFUL LAPBAND SURGERY

* 4/14/11 - 3RD DOCTOR VISIT (lossed 4 more pounds - now at 274) Re-emphasized the insurance program requirements for lapband. Again the doctor was kind of negative again....HE HAS THE MOCHO ATTITUDE saying its not a big deal....just lose the weight even though he knows my families history of obesity.

*5/25/11 - 4TH DOCTOR VISIT (gained 2 lbs - now at 276). Doctor got mad that I gained 2 lbs. I told him hey...I lossed every other visit...stop giving me a hard time. Again...he was kind of arrogant and prideful when it comes to losing weight.

* 6/14/11 - 5TH DOCTOR VISIT (lost 6.5 lbs - now at 269.5) Told the doctor that we needed to submit the paperwork and have him fill out a sheet that my lapband surgeon's office told the doctor to fill out. The form was documenting each visit and documenting if I followed the behavioral modifications and dietary modifications ect...

I just got off the phone with my insurance company and they said they denied me because I did not conform to the behavioral and dietary modifications based on what the doctor submitted. She said however, I can dispute and appeal this denial. So the question is....NOW WHAT DO I DO? Please note that my doctor never asked me if I did certain behavioral modification of diet even though I did. I just think he was turned off that I wanted the surgery and how I was trying to get it approved through insurance. To me...you can't blame me for wanting to get the surgery.

ANY ADVICE ON WHAT I SHOULD DO? PLEASE NOTE MY WIFE'S HEALTH INSURANCE IS ONLY GOING TO BE AVAILABLE FOR ANOTHER 100 DAYS (UNTIL AUGUST 31ST).I really want this surgery and to not have to go to Mexico to get it. It would only cost me $175 out of pocket with my current insurance provider and wouldn't have the added risk of traveling to Mexico. The option of going to another doctor is not a valid choice since I my insurance coverage is only valid for another 100 days.

Discouraged,

MD

[Juliat 6]

I didn't go through insurance, but just reading your story I think you should go back to the doctor and give him a 'what for'. This is your life not his and as a patient, he should have your best interest at heart. Don't let him bully you and find out why he did what he did and not tell you. Seems unseemly to me.

Keep going at it.. If you just need to get his ok, wear him out to get it.

J.

[marketingdude 79]

I didn't go through insurance, but just reading your story I think you should go back to the doctor and give him a 'what for'. This is your life not his and as a patient, he should have your best interest at heart. Don't let him bully you and find out why he did what he did and not tell you. Seems unseemly to me.

Keep going at it.. If you just need to get his ok, wear him out to get it.

J.

Thanks Juliat for your response. It seems if I want this covered...I DEFINITELY NEED TO STAY WITH THE SAME DOCTOR....its just now...how do I get approved. I could go back to my original doctor in 2005 as they will have a chart on what I weighed in 2005. I've literally gained 75lbs in 6 years since moving from Arizona to Illinois. Submitting this, my foot doctor records, and going back to the doctor I have now and confronting him....is the only thing I can do.

Now...THE BIGGEST CHALLENGE is going to convince the medical director from your insurance....to justify approving me when your own doctor said I didn't comply . HOW IN THE WORLD DO YOU OVERCOME THIS as the doctor doesn't want to admit he was wrong. To me...convincing the medical director is going to be THE BIGGEST CHALLENGE when your own doctor said you didn't comply.

THOUGHTS?

[stateofzen 46]

Go back and talk to your doctor.

If he was against lapband surgery, the ethical thing for him to do would be to tell you upfront, not sabotage your medical record after you went through the process.

HIPAA law gives you the right to see your medical records, and challenge anything in your medical record. I am not sure how one goes about doing that, but you should start with him and his office . Become familiar with HIPAA and let him know you are familiar with it. Don't get me wrong-- it isn't sueing, but you do have the right for your medical records to be correct.

http://privacy.med.miami.edu/glossary/xd_amendment_rights.htm

http://medicalrecordrights.georgetown.edu/stateguides/az/az.pdf

If you can't get him to resubmit new information, then appeal with the insurance.

Good luck. This is truly unconscionable and another piece of evidence that obese people get treated like crap by many old-school doctors who are so behind the medical research they don't even know their "willpower" talks are based on obsolete medical ideas.

[brbm6 6]

Find a Bariatric surgeon and let the insurance claim rep. in their office be your advocate. I was denied the first time and when the woman who files the claims got involved they automatically began working towards my approval. I think sometimes it is easier for insurance to deny at first and assume we will give up. Hang in there, get all the records from the foot doctor and tell your primary care doc that you are not happy with his remarks. Obviously if it were easy for us to deal with our food issues we would all be at a normal weight. Your primary doc should be ashamed of himself! I would think he would see it as medically necessary....especially given your family history.

[marketingdude 79]

Go back and talk to your doctor.

If he was against lapband surgery, the ethical thing for him to do would be to tell you upfront, not sabotage your medical record after you went through the process.

HIPAA law gives you the right to see your medical records, and challenge anything in your medical record. I am not sure how one goes about doing that, but you should start with him and his office . Become familiar with HIPAA and let him know you are familiar with it. Don't get me wrong-- it isn't sueing, but you do have the right for your medical records to be correct.

http://privacy.med.m...ment_rights.htm

http://medicalrecord...uides/az/az.pdf

If you can't get him to resubmit new information, then appeal with the insurance.

Good luck. This is truly unconscionable and another piece of evidence that obese people get treated like crap by many old-school doctors who are so behind the medical research they don't even know their "willpower" talks are based on obsolete medical ideas.

I hear what you are saying for sure. The challenge I see here is I told the doctor about this 6 month weight loss program technically 2 months from the first visit. Again...I didn't find out the surgery was covered until 2/1/11 of this year. So...in theory...was this a full blown medically supervised weightloss program meant to submit to an insurance company....NO...ABSOLUTELY NOT. However, I did meet him on 12/14/10 with wanting to lose weight, he advised me of some things like Portion Control excercise and he gave me some phentermine pills to help along the way.

So when you say....medical records ect... designed to submit to the insurance company....technically and formally this wasn't an "OFFICIAL WEIGHT LOSS PROGRAM until 2 months into it. However...when I told him about this plan....he outright was negative as he thinks I'm taking the easy way out.

I AM OPEN TO YOUR SUGGESTIONS.....BUT AM SOMEWHAT CAUTIOUS ABOUT BEING TOO PUSHY AS HOW THIS OFFICIAL WEIGHT LOSS PROGRAM/APPROVAL CAME ABOUT.

[marketingdude 79]

THE #1 THING I HAVE TO OVERCOME WITH THIS APPEALS PROCESS NOW IS CONVINCING MY DOCTOR TO REBUTTAL/CLARIFY HIS CLAIM THAT I DID NOT COMPLY WITH CALORIE REDUCTION AND BEHAVIORAL MODIFICATION PLAN. The doctor never asked me questions if I did this or that on subsequent follow-up visits....so how can he say this?

How would you recommend I approach my doctor to convince/clarify his statements (to the medical director of the insurance company)? The only way this surgery will get approved if he convinces/clarifies his statements to the medical director as the doctors statements failed to meet surgery guidelines of compliance.

THOUGHTS?

[CheckYes 46]

Does behavior modification mean exercising? If so, maybe join a gym and present that information to him as evidence of your commitment.

[marketingdude 79]

Does behavior modification mean exercising? If so, maybe join a gym and present that information to him as evidence of your commitment.

Good question CheckYes. The form (that I got from my bariatric surgeon's office) which I gave to the doctor to fill out and send to the insurance company asked the following 3 questions:

1) Has the patient been complient with calorie reduction? My doctor responded NO (which how can he say this as he never asked me...again...he just doesn't believe in the lapband because of his macho view of weightloss).

2) Has the patient followed the excercise/activity plan as instructed? My doctor responded Yes (he must know that I really do enjoy working out....not sure)

3) Has the patient been compliant with behavior/lifestyle modifications? My doctor responded NO (again....how can he say this....he never even asked me. He kept on saying periodically that all you need to do is to eat small portion sizes ect...)

I know the insurance company based their decision quickly on these 3 answers as he never wrote any other notes on the paperwork outside of signing his signature (the doctor's office gave me copies of what they sent). The insurance company received my paperwork from the doctors office on 6/15/11 and this letter (which I have in my hand tonight) is dated 6/16/11. So I know they made their decision very quickly and in reference to the 3 questions above.

Again...anybody have any advice on this as the state of illinois is going with a different insurance company that does not cover the lapband procedure?

Thoughts?

[Karon 1]

Thanks Juliat for your response. It seems if I want this covered...I DEFINITELY NEED TO STAY WITH THE SAME DOCTOR....its just now...how do I get approved. I could go back to my original doctor in 2005 as they will have a chart on what I weighed in 2005. I've literally gained 75lbs in 6 years since moving from Arizona to Illinois. Submitting this, my foot doctor records, and going back to the doctor I have now and confronting him....is the only thing I can do.

Now...THE BIGGEST CHALLENGE is going to convince the medical director from your insurance....to justify approving me when your own doctor said I didn't comply . HOW IN THE WORLD DO YOU OVERCOME THIS as the doctor doesn't want to admit he was wrong. To me...convincing the medical director is going to be THE BIGGEST CHALLENGE when your own doctor said you didn't comply.

THOUGHTS?

I had the same thing happen to me. However, we never even bothered to submit my records to the insurance as the program coordinator at my surgeon's office looked over the notes and they said I really hadn't complied or lost any weight and she knew that insurance wouldn't approve me. The only option available to me was to do another 6 month diet. This time, I said the right things and did the right things and lost 41 pounds. I was approved. I know this is not what you want to hear as you have a time requirement. But if your wife's insurance ends in 100 days, how will you be able to get your "fills", which you will need every 4-6 weeks? You will be seeing your doctor for the next 2 years, if not longer, so how will you handle those expenses?

[marketingdude 79]

I had the same thing happen to me. However, we never even bothered to submit my records to the insurance as the program coordinator at my surgeon's office looked over the notes and they said I really hadn't complied or lost any weight and she knew that insurance wouldn't approve me. The only option available to me was to do another 6 month diet. This time, I said the right things and did the right things and lost 41 pounds. I was approved. I know this is not what you want to hear as you have a time requirement. But if your wife's insurance ends in 100 days, how will you be able to get your "fills", which you will need every 4-6 weeks? You will be seeing your doctor for the next 2 years, if not longer, so how will you handle those expenses?

If I have to...I'll pay cash. The big expense is the surgery obviously. Good thinking though...I'm liking how you thoroughly thinking this out. Many thanks for your advice/thoughts.

[Humming Bird 275]

If all else fails, there are many surgeons here in the U.S. that charge around $10,000 and include aftercare in that figure. I financed mine and the min. monthly payments started out at around $100 per month. (I would guess you are paying more than that for the health ins.) I did my best to make large payments and paid off the surgery in about 18 months. I had no insurance hoops to jump through and was banded a couple weeks after my first consult.

I understand wanting to use the ins. if you can, but just saying all is not lost if you can't do it that way.

[marketingdude 79]

1. First visit would have been last visit and I would have found another doctor. Get his documentation and find yourself another doctor.

I didn't find out he was negative about this until after 2 months when I actually found out this surgery was approved. Theoretically, I could have start over but would have never dreamed he would be like he is now.

It can't hurt to confront him and tell him...look...I want this surgery....here is a letter that I want you to sign and fax over to the doctor (they denied me because of your FALSE STATEMENTS). The only way they will approve this surgery now is if you clarify what you actually meant.

P.S. Retail surgery for this is around $22,000 and I'll tell the doctor...look I got $22,000 reasons why I'm pissed off right now.

[Corize 2]

Call your health insurer right away and ask them the process for appealing. You may need to send them a letter stating that your doctor has misunderstood what you relayed to him and that you have been making an effort, including weight loss drugs, dieting, and exercise, without success. You may also need to see your doctor again, and explain to him that you feel he has 'misunderstood' you and that you would like his visit note to reflect that you have been following his instructions. I think brbm6 is right. A lot of insurance companies deny at first, figuring if you accept the denial, you just saved them some money. My initial doctor was the same way. She thought that everyone could easily just watch what they eat and exercise and the world would be right. I wish it were that easy.

[marketingdude 79]

Call your health insurer right away and ask them the process for appealing. You may need to send them a letter stating that your doctor has misunderstood what you relayed to him and that you have been making an effort, including weight loss drugs, dieting, and exercise, without success. You may also need to see your doctor again, and explain to him that you feel he has 'misunderstood' you and that you would like his visit note to reflect that you have been following his instructions. I think brbm6 is right. A lot of insurance companies deny at first, figuring if you accept the denial, you just saved them some money. My initial doctor was the same way. She thought that everyone could easily just watch what they eat and exercise and the world would be right. I wish it were that easy.

Thanks for responding Corize. Part of the policy for approval is that YOU MUST ADHERE TO BEHAVIORAL MODIFICATIONS AND ADHERE TO THE DOCTORS DIETARY PROGRAM. SO THEY WON'T ACCEPT MY DOCTORS RESPONSE. THE ONLY WAY THEY WILL ACCEPT THIS IS IF HE CLARIFIES WHAT HE WROTE AND HE WRITES THAT HE DID NOT MEAN TO SAY I DIDN'T ADHERE TO THE WHOLE DIETARY PROGRAM AND BEHAVIORAL MODIFICATION PROGRAM.

At least...this is what it seems...that the only way they will cover it now. I am getting my doctor records from 2005-2009 from my other doctor to show my weight then and how I was stressed ect...and my foot doctor records to show how this increase in weight gain even now effects the arches in my foot which causes even more pain and stress.