Misleading Surgeon Office - Non Credentialed Surgeon

[DrinkMoreRadium 16]

So I started the process in September and definitely was not prepared for how much time everything would take mainly due to the insurance requirements around a weight loss trial. I thought everything I had done in the past would have counted, but it did not so I had to start a new weight loss trial. My primary care put in a referral and Tricare approved it for Dr. A at a surgeon's office over an hour away (closest bariatric specialty). When I tried to schedule the appt, I was told that Physician A is revamping his practice and would like to have me be scheduled with Dr. B. I agreed, as long as the referral was still good. Apparently that was not quite the question I should have asked. Fast forward to 4 months later, my weight loss trial and all the pre-reqs are done. I emailed the clinic with all the information and had not heard anything in 10 days, so I asked for an update.

Today's update is this: Dr. B is not yet credentialed with Tricare so they can't even submit for approval until that is done. They have no estimated time frame and can't tell me when the process started. According to Tricare's website, it can take 60-90 days for a new provider to be credentialed. Additionally, when I asked if I could have my surgery done by Dr. A since Dr. A did my EGD and all my labs, they responded saying they asked Dr. B and he said no.

I'm beyond frustrated because I only have a small window remaining where I can take off (Feb - Mar). After that, I will have to put it off until August or September. To clarify, I don't work a standard full time job. I am a contractor working through a recruiting company for a hospital org to implement the software system and their go-live is in July. I don't get paid for time off and I don't get FMLA. So now I'm either stuck in limbo for potentially months until they get him credentialed or I could see if another surgeon would be willing to take all the existing labs/imaging/documentation.

[The Greater Fool 2,024]

The best laid plans of mice and men (and doctors and contractors) oft go astray.

Generally, documentation for the goose is documentation for the gander, or something like that.

The insurance sets most of the documentation standards.

Good luck,

Tek

[Old Salt 64]

You stated "My primary care put in a referral and Tricare approved it for Dr. A" and "my weight loss trial and all the pre-reqs are done". So I am assuming you completed these thru your Primary Care Doctor and they have all the documentation. I also assume you have Tricare Prime not Tricare for Life (what I used), either way you have recieved insurance approval.

You must be in the panandle or down in the muck near Clewiston but there has to be more Bariatric surgeons than just that one office within an hour. But I woud NOT go with a surgeon that is still seeking insurance credential. Tricare is adminstered by Humana which is not a small organization. There are many Bariatric Surgeons throughout Florida. Just curious, is this specific surgeon in the same medical network as your primary doctor?

I would request a new surgeon or center thru your Primary Doctor. Submit all the "completed" documentation to a new surgeon and explain your employment situation. They might still be able to sched for March/April

[liveaboard15 1,293]

i dont know what part of Florida you are at but i got my surgery done at the Baptist Bariatric Center in Jacksonville, Florida. They have several surgeons. Process was pretty simple.

[DrinkMoreRadium 16]

16 minutes ago, Old Salt said:

You stated "My primary care put in a referral and Tricare approved it for Dr. A" and "my weight loss trial and all the pre-reqs are done". So I am assuming you completed these thru your Primary Care Doctor and they have all the documentation. I also assume you have Tricare Prime not Tricare for Life (what I used), either way you have recieved insurance approval.

You must be in the panandle or down in the muck near Clewiston but there has to be more Bariatric surgeons than just that one office within an hour. But I woud NOT go with a surgeon that is still seeking insurance credential. Tricare is adminstered by Humana which is not a small organization. There are many Bariatric Surgeons throughout Florida. Just curious, is this specific surgeon in the same medical network as your primary doctor?

I would request a new surgeon or center thru your Primary Doctor. Submit all the "completed" documentation to a new surgeon and explain your employment situation. They might still be able to sched for March/April

You are correct- Tricare Prime and I am on the panhandle. Unfortunately my primary care is the base physician and she may be able to put in another referral but it's whomever Tricare approves it for (if they are willing to approve a second). There are 2 physicians in an hour radius that are in network. The original Dr A. I was supposed to be with and 1 other. I have been able to change the approved referral in the past if I call Tricare but only prior to being seen.

The other issue is the dietician consult, psych eval, and EGD were all done by the surgeon's office, but I could probably get those records.

[Old Salt 64]

I had my Primary change my referral to a different surgeon when I first started the process.

However, if all of your pre-op paperwork is with that one surgeon's office, that probaly will be a problem. But worth a try.

Curious. Why hasn't Surgeon B been credentialed with Tricare when his cohort in same office is? Is Surgeon B new?

[DrinkMoreRadium 16]

Old Salt - yes he's new to the practice as of last year. If I had known that and that he wasn't credentialed, I wouldn't have agreed to swapping the consult. Thanks for the advice- especially experience with Tricare. I'll send a message to my primary and see what she's willing to do.

[Jeanniebug 473]

I can't help with the insurance snafu, but I can sympathize. I had a 9-month delay in my process. But, it was a blessing in disguise. It allowed me more time to think, more time to plan, more time to research life after surgery, more time to establish a relationship with a therapist, and more time to be convinced that I really needed the surgery.

Things tend to happen when they're supposed to. There's a reason for your delay. You may not be able to see why, but life will be easier if you can trust the process.

[LindsayT 594]

Do any of the military bases have a hospital that does the surgery? I'm getting mine done at an Army hospital here in Colorado. I do advise some caution, though. Our bariatric center here has high standards and is a Bariatric Center of Excellence. Good luck.

Sent from my SM-S908U using BariatricPal mobile app

[DrinkMoreRadium 16]

4 minutes ago, LindsayT said:

Do any of the military bases have a hospital that does the surgery? I'm getting mine done at an Army hospital here in Colorado. I do advise some caution, though. Our bariatric center here has high standards and is a Bariatric Center of Excellence. Good luck.

Sent from my SM-S908U using BariatricPal mobile app

Unfortunately no. Very few services are available on the base for dependents. I did another search for in network providers in a 150 mile radius and this office is the only one. There's a ton that are out of network....

[LindsayT 594]

Unfortunately no. Very few services are available on the base for dependents. I did another search for in network providers in a 150 mile radius and this office is the only one. There's a ton that are out of network....

Bummer. Hopefully, this office gets its credentials soon.

Sent from my SM-S908U using BariatricPal mobile app

[Grammy Kaylee 5]

You are always entitled to a second opinion. Or second doctor. They have to provide you with your records and /or send records to new doctor. It is not up to Dr B to decide if Dr A can do the surgery. It is up to Dr. A. . I would contact and request an appointment with them if possible. Or get a recommendation from Tricare for some even if a little further out.
I am speaking from experience because after having my 6 months of nutritional visits, psych evaluation, cardiac clearance, other medical clearances that were required, and upper endoscopy, and multiple other things my insurance denied me having surgery saying that it was not medically necessary even though I met every bit of the criteria and my PCP had referred me to having the surgery. I ended up having to change doctors 7 months into the process because where my husband works they also have transcarent which is a plan that will help pay for surgeries. The initial surgeon that I was saying did not take it so I had to go to a different doctor transfer all my records to them . I had my consultation one week , pre-op the next week, and surgery the next. I had to be sure that I had it all done in the month of December because I did not want to have to start over on paying my deductible and everything else with my insurance because we had already met our deductible and out-of-pocket expense for the year.
So thankfully I had surgery on December 28th and all is well.

Good luck!

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[DrinkMoreRadium 16]

I ended up pushing the office on at least providing a date when Dr. B's credentialing process started and mentioned that due to work if it's going to take longer than 2 months, I will have to move to another provider. The insurance rep (who has been super nice and understanding) said the office manager is allowing me to switch rather than lose me as a patient because they cannot provide any timeline for the credentialing to go through. They submitted me same day under Dr. A and it was approved the next day.

This is honestly the best outcome because I have done a lot of research on this doctor and am confident in his abilities as a surgeon. Thank you to everyone who encouraged me to keep pushing!