The Insurance Hoops Dance

[theantichick 2,204]

Well, this whole thing has just gotten a lot more "real" for me. So I guess I'll start the "my story" part.

I've been overweight my whole life. First diet as a pre-teen. Lots of family of origin stuff. Likely a similar story to a vast majority of the people here. I did pretty OK as an active "fluffy" woman for many years - did belly dance, went skiing, took Krav Maga... as someone else said here, I was healthy and doing well, until I wasn't. A knee injury ended up with a knee reconstruction and 18 months of rehab, then I decided to change careers (IT to nursing) and my weight started climbing through nursing school and my health started crumbling. First I was diagnosed with sleep apnea, then my irritable bowel flared up, then I had a reaction to a medication and ended up needing a heart procedure (all fixed). Then I graduated from nursing school, and thought the active job would help. Then aches and pains in joints, especially my feet, started me on a hunt for a diagnosis. Auto-immune arthritis changed everything for me. Without medication, I was rapidly approaching a point where I couldn't do my job as an ER nurse. With medication, I'm susceptible to infections, which doesn't bode well for a nurse, especially in the ER. I started treatment and left my dream job. Luckily, I have extensive IT experience and coupled with my RN and ICU/ER experience, I was able to transition into a healthcare informatics job. That's when I realized that the 13,000 steps per shift (3 times a week) was actually helping in relation to my weight, because the scale started trending up almost immediately after changing back to a desk job. Topped 300 lbs (which had been my "I will never let myself be that weight" weight) and I started seriously considering VSG. Discussed VSG with my rheumatologist who enthusiastically supported it.

Now I'm going through the insurance hurdles. Met with the surgeon, very much liked her. Met with the nutritionist, who was about what I expected and had nothing new to offer me. This week I went back to my cardiologist to ask for surgery clearance. When he did my procedure 4 years ago, he wanted a followup stress test after a year. A couple of scheduling screw-ups (one on his staff, one on my part), several job/insurance changes, night shifts, and then the auto-immune stuff kept me from getting that done. However, in the ICU and ER I had many opportunities to offer myself as a test subject for people learning to do EKG's so I knew my heart was fine. Anyway, he was really encouraging about the surgery and scheduled me for a stress test next week so he can clear me ASAP. I meet with the doc in my surgeon's office who does her supervised diet followups, as my insurance requires 3 months of that silliness. My rheumy will write the required 2nd opinion that I need surgery, and then I need to get my therapist to clear me or if she won't (I'm seeing her for food issues, but she's mildly opposed to the surgery on principle) go see whoever my doc's office has. Since I already have sleep apnea and sleep with my CPAP, I don't need a sleep study. I swear, all of this nonsense is going to cost me hundreds of dollars in copays before we even get to the EGD and VSG. Luckily I've already almost met my deductible for the year.

I feel like I'm in limbo right now, doing the insurance hoops dance to get approval. So it hasn't been feeling "real" but somehow felt so much more so when I met with my cardiologist. We're targeting early August for the surgery, and that seems so far away. But it's not, really.

In some ways I'm incredibly lucky. I have a super supportive husband who loves me no matter what weight I am, but who will also do whatever he needs to support me in being healthier. He'd love to be more active than my current situation allows, and prefers to eat healthily. So I won't have him sabotaging me or being unsupportive. My closest friends (chosen family, really) are concerned because we know people who have had serious complications (and a couple for whom the surgery may have contributed long-term to their deaths) but they are also super supportive. I have a sister who had the VSG several years ago in S. Korea, and she's been pressuring me to have it ever since. Which is nice, but she's one of those people who are convinced her way is the only way, so it can also be very annoying. My Dad thinks I just need to buck up and eat right and exercise, and my Mom is worried that the complications my sister has had (not really related to the surgery, except in Mom's mind) and doesn't want me to do it. I have a good job that is not very physical, so my time off work will be minimized (I'm planning one week completely off, then working from home 1-2 weeks as needed) and my boss is super supportive.

So really, I have everything I need. It'll be up to me to follow through with this and do what I need to do, in order to be healthy. And learn some patience until this summer.

[theantichick 2,204]

And of course, my appointment for this month's "supervised diet" meeting with the doc got re-scheduled. They tried to push it out 2 weeks, and I griped that they were pushing out my surgery date, so they worked me in next Friday.

The insurance hoops are ridiculous.

[theantichick 2,204]

One more hoop down. Got my cardiologist clearance today after a stress test. I had to have a minor procedure 4 years ago. My cardiologist is all in favor of the sleeve, but kept reminding me that it only works if you keep on the plan. It was reassuring to have the test done since I'm looking forward to getting back in shape once I can move better.

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[theantichick 2,204]

Argh.

So today I went for my 1st appointment with the doc that does my surgeon's supervised diet stuff. (Counts as the 2nd visit for the supervised diet for insurance, which is good.)

First off, I was supposed to see him last week. They called several hours before the appointment to re-schedule for 2 weeks out. I told them that's not acceptable because I am trying to get the insurance stuff done as quickly as possible to get my surgery in August if possible. I work across the street from the doctors' building so I'm available literally any time. They "worked me in" for today.

I got there 15 minutes early for my 2pm appointment, and spent 10 filling out paperwork. All of my docs are on the same electronic records system, so I get a little bent about having to fill out the same history crap every time I see someone else even if they're associated providers. Then I wait. And Wait. 2:20 I finally go back to the room, and 2:35 the doc comes in.

Now I completely understand that I'm not the average patient. I'm a nurse, and have been a medical geek since I was a teenager. I have also done every diet under the sun, and studied nutrition as an elective in my nursing program. He didn't come right out and say I shouldn't have the surgery, but he was trying to get me to agree to go on one of his programs with shakes and powders and such. Ok, whatever. And he talks over me through the entire 30 min visit. He wasn't unpleasant, or judgemental, I just have known everything he's trying to tell me for years. Including all the recent research on set point. So it was a complete waste of my time. He did tell me that if I'm really doing a 2,000 cal diet, that I should be losing weight because my metabolic rate from testing was a little over 3,000. However, that's the active rate, my resting metabolism is 2152. I don't do any exercise between the fatigue and joint pain from my auto-immune disease. I'm trying, but the 5 minutes on the treadmill yesterday for my stress test knocked me out, I slept 12 hours last night and am still beat. And while I'm trying to keep it to 2,000, I know realistically I am probably off on my counts from portion estimation. So it doesn't surprise me that I'm not losing weight, and it doesn't mean I'm not watching what I eat. Grrrr.

I went straight upstairs to talk to someone in my surgeon's office to find out what the actual insurance requirement is. It's only one more visit, supposedly. So I'll buck up and see this guy again just to get the sign-off. My EGD is scheduled for next week. Then I have to do the psych visit and get my rheumy to write a recommendation for surgery. Then the last visit with the doc I saw today, and we'll be golden for insurance review.

This is beyond frustrating.

[theantichick 2,204]

EGD done today. Amazing that it takes an hour and a half to register and get prepped for a 10 min procedure. And another hour to get released. But looks good, they're checking for H. pylori infection, and one more item checked off the list.

[theantichick 2,204]

Last appointments for meeting insurance requirements are set. Psych on 6/28 and last supervised diet visit on 7/1. Hopefully this will allow everything to get sent to insurance and approval early enough to schedule for mid-August between my school semesters. It's starting to feel real.

[theantichick 2,204]

ARGH.

So my rheumatologist told me when I asked her about VSG that it would absolutely benefit me, in more ways than just losing weight for my joints. She said the changes in hormones would directly impact my arthritis in a positive way.

So when insurance said they needed a referral from someone other than the surgeon, I thought my rheumy would be perfect. And her office actually responds to emails through the patient portal. So I emailed what I needed.

Her staff emailed me back today that she can't do that, because she's treating me for psoriatic arthritis and that has nothing to do with gastric surgery. That I have to get that from my primary doc.

So add one more freakin' appointment to the list of things to freakin' do, one more freakin' copay, and more time off work, since my primary isn't close to my office. And, I don't know if my primary will agree with the surgery. She's been on me about diet for years, but gets caught up in fads... her latest one was telling me with the auto-immune I needed to go gluten-free. Before that it was paleo and low-no-carb.

Oh, well... will tomorrow and see what I can set up. Fingers crossed. I don't know what I'll do if she won't write the note.

[theantichick 2,204]

Have an appointment for the 27th. I'm trying not to stress about this. I have a tendency to get worked up over things that never become an issue the way I expect them to. My doc might be thrilled that I'm finally doing something about my weight that she's been hammering on me about for years. She may not have any biases against bariatric surgery.

I will say, though, that if she refuses to send the letter, I'm finding a new doc. I fired her once before for shoving anti-depressants at me because my symptoms were not backed up by labwork. After I ended up being diagnosed with sleep apnea and needing a heart procedure, I ended up going back to her after problems with the office staff at the doc I'd started seeing. I like the family practice clinic, they always have PA's or NP's I can get in to see if my doc isn't available and it's urgent. It's very convenient, between my home and office. I like my doc quite a bit. But I will not hesitate to go elsewhere if I need to.

I'll be so glad once all the hoops have been jumped through and the insurance approval is given. Then I'll be able to relax. Well, except for stressing about the pre-surgery diet and the post-surgery diet... the surgery itself does not scare or stress me at all... it's the fear that I can't do the diet changes that stresses me.

[theantichick 2,204]

It's doctor week. I see my PCP this afternoon, and am stressing over what she will say. I do not want to have to fire her and find a new PCP while I'm trying to get this surgery approved. I'm really hoping she's just glad I'm finally doing something about my weight, she's been on my case about it for years.

Tomorrow I get my psych eval. I'm not worried about it in the slightest, it's just one more copay I have to deal with in this whole process. Though I do have to remember to put my checkbook in my purse, the doc only takes cash and checks.

Friday is my last weigh-in with the supervised diet. I don't think I've lost any weight, I have had real problems sticking to the diet for a number of reasons. My family and I sat down this weekend and had a heart-to-heart about what's going to have to change in the house food-wise. My daughter is worried about her weight, my husband wants to eat healthier, so this will happen. We just had too much going on the last month with family visiting and an upcoming trip and everything to really deal with it. But we have a plan for when we get back from vacay.

I'm really hoping that the insurance company doesn't throw any more roadblocks up. I have a gap between school semesters in August that would be ideal for the surgery, and things are (knock on wood) slow at work right now but are due to really pick up this fall. So I'm crossing my fingers for a quick approval and a surgery schedule that fits right in the gap.

We'll see.

[theantichick 2,204]

I am relieved. My primary is happy I'm doing something about my weight, especially since my blood pressure is way high and didn't really come down after resting 20 min. So I'm getting a new BP med, and approval for surgery. The med well get discontinued after some of the initial weight comes off and I get more active. And this is one more co-morbidity to give the insurance company.

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[theantichick 2,204]

Ok, Psych eval done. That was strange. I mean, I get all the questions he asked about my health and other therapy I'd had, my weight, the surgery. But the questions about things in the news, repeating strings of numbers back to him... I'm wondering what the point of all that was. Anyway, I didn't get any vibe that there would be an issue.

One more weigh in with the diet supervising doctor on Friday.

And my primary said she needed to hold off writing the recommendation letter until I see her on the 11th to make sure the new BP med was doing its job, but otherwise she's all for the surgery. Just wants me to be safe and not get rejected by the anesthesiologist the day of the surgery.

So things are coming along swimmingly.

[theantichick 2,204]

Well, drat. What should have been my final weigh-in may not be. When I saw my primary on Monday, I weighed 298. Today I weigh 302. Which is an increase from the last weigh-in from this doc. And is likely due to inflammation levels being high as I haven't eaten enough to gain 4 lbs in 4 days. Grrr.

But we'll see. I also have to see my primary again on the 11th to see if the high blood pressure med is working, so if I'm down on that scale again I might be able to make the argument that this doc's scales are whack.

I refuse to stress about this until we get an answer back from insurance.

[theantichick 2,204]

And drat again. BP is down, but not to normal levels yet, so we're adding another BP med and re-check in 10 days, my PCP can't release me for the surgery until it's to normal levels on meds. The good part is that I'll be off of the meds a few months after surgery, most likely. But now it's getting close enough I'm worried we'll have to push the surgery out, and I'll have to be doing school while I recover. Which isn't a deal breaker, but it's annoying. However, this is also just more confirmation that it's past time to do the surgery and get this weight coming off.

[KristenLe 5,979]

@@theantichick The weight gain may have been a result of the blood pressure med change. Hopefully they added a diuretic and you'll be down again.

[theantichick 2,204]

No, she added Valsartan, which I don't think has any significant diuretic effect. She's trying to get my BP down to a normal range before she approves me for surgery. I see her again in 10 days to see if this med helped. If it doesn't, I'll ask about a diuretic at least until surgery. I don't want to be taking a diuretic after surgery when we're trying to keep hydration levels up.