my blue shield HMO medical group exp so far

[taylormomto6 0]

I have BS HMO and just filled out the "weight loss surgery education criteria checklist" with my PCP to see if they will accept me into their program. If they accept me, I'm to join their 6 month weight loss class and simultaniously attend wls education classes at the medical group.

Apparently the educators will then submit a psychological profile on me to qualify me for surgery. I must attend all sessions, comply with all assignments and exercises as determined by the counselor, show that I will be able to practice necessary post op lifestyle changes and not have any significant psychological problems.

I looked at the website of my medical group and the next weight loss class begins in July. Not real thrilled about waiting until then, but thats the way it goes. So the best I'm looking at is a surgery date after Jan 09.

Anyone have to go through their medical group like this?

Cindy T

[taylormomto6 0]

No one has had to go through their medical group like this? No comments??

Cindy T

[peg pugh 0]

I am starting my 6 mo. program tomorrow.And I don't have Ins. approval yet.They want an unbelievable am't of info.I pay for the 6mo.and then possibly by then I will be ok'd by ins.If not, I don't feel it will be a waste it all sounds like something I can use and almost necessary for success.Dr. Sewell's book highly recommended going the distance on the 6 mo.pre-op program.

[taylormomto6 0]

Thanks peg,

yeah, I'm not at all upset about the 6 month diet. I understood that was going to be a requirement and I agree, it'll be informative.

I'm most interested to know if others that have HMOs have had to go through their medical groups like this. If they accept me into the "teaching program" does that mean they will approve me as long as I jump through all the hoops?

I called them today and they said they received the referral a week ago and it should be processed today, so I'm thinking approval for an educational class should not be that difficult if entry into the classes wasn't a type of preapproval for the surgery (of course that would be dependent on all the hoops being cleared).

I also still do not know where the surgery is done. Blue Shield lists no bariatric surgeons that accept HMOs within 250 miles, so I'm not sure where they send us. Of course there are several nearby that accepts Blue Shield PPOs, but I just can't squeeze out another 200 month to change it right now.

Anyway, I guess I'll find out soon enough.

Cindy T

Maybe I'm just wishful thinking:embaressed_smile:

[AMLP 4]

Hi I just start the BCBS 6 month diet. I have a BMI of only 38 not the 40 they are looking for so I really don't want to lose any more weight just to be denied for surgery. Its very frustrating to have this waiting game!

Amy

[peg pugh 0]

don't you just love this sitting on eggs thing?? I have PPO...I'm covered supposedly and have all of the requirements met, except heart disease and i still feel like I am getting the run around.

[mesaucy 0]

I have BS HMO and just filled out the "weight loss surgery education criteria checklist" with my PCP to see if they will accept me into their program. If they accept me, I'm to join their 6 month weight loss class and simultaniously attend wls education classes at the medical group.

Apparently the educators will then submit a psychological profile on me to qualify me for surgery. I must attend all sessions, comply with all assignments and exercises as determined by the counselor, show that I will be able to practice necessary post op lifestyle changes and not have any significant psychological problems.

I looked at the website of my medical group and the next weight loss class begins in July. Not real thrilled about waiting until then, but thats the way it goes. So the best I'm looking at is a surgery date after Jan 09.

Anyone have to go through their medical group like this?

Cindy T

Hello Cindy, I also have Blue Shield HMO California, and I am currently in my 3rd month of the 6 month medically supervised diet. I also have to do a psych evaluation, and medical exam. I wish they would have told me this in November 07, when I first asked for a referral, my 6 mo. would have been up in April 08, now I have to wait until August. but that is okay. I am really thinking can I do this on my own, you really cannot eat the same especially carbs. Can anyone who has had the band tell me what you can tolerate after?

[Froggi 4]

My insurance requires all the same things yours does taylor. The time really does go quickly. I should be having my surgery in November.

Thing is even if they accept you into the program you can still be denied afterwards if you don't pass your psych eval or don't do something right in your 6 month time.

I have 5 months left then have to fax all my paperwork from the 6 months in and wait for a response.

Let us know how things go.

[taylormomto6 0]

OK, well at least I finally got approval to join the medical groups (Bakersfield Family Medical Group) Weight Management program. It doesn't begin until July 17 though.

These people are seriosly trying to get us to lose weight without the surgery. The first 9 weeks is a weekly class on nutrition and exercise. All food and exercise must be logged in a journal and they do measurements and weeekly weigh ins. Then it moves to every 2 weeks where I'll meet with the Health Education Centers rep for the remainder of the 6 months. At anytime that the consider I'm not doing so well, they refer me to the nurse:mellow: I guess for a beating lol. I'm guessing during this 6 months I should not let my BMI drop below 40?

Then, I believe they will put me through their WLS teaching class as well. At this time they'll do the psyc eval. After that I'm guessing will be the medical tests. Then I guess they'll approve or deny.

mesaucy- since you have BS Ca HMO, do you know a surgeon that takes this insurance? Actually, I think they even have to be contracted with the medical group.

They really are trying to trip you up it seems. Making it difficult so they can find an excuse to deny.

Well, there's my update. I'll add more after I start the Weight Management class.

Cindy T

[mesaucy 0]

Hello Cindy, Dr. Higa, Boone, and Muhammed take this insurance they are in Fresno, ca, and I heard they are the best. But they do let you know which insurance plans are better like denials and approvals, and what you need to do.

[taylormomto6 0]

Thank You mesaucy. At least I know where my surgery will be LOL.

They are giving me the runaround already. Got a letter yesterday requesting I call "for an appointment"...when I did she said I had been put on a waiting list...no, I had already been signed up. Anyway, I go in today for measurements and I think she signed me up for the class...who knows.

I'm also out of town, 35 miles, so this is going to be pricey.

I'll update later after my appointment.

Cindy T

[iwalktheline 1]

I have bcbs/il HMO and decided to have lap banding. I called bcbs and asked what my coverage was and the cs said that it is covered 100% if there is a referral from my PCP deeming it med nec. I was sooo happy that I felt like my life was going to finally be worth living because I wasn't stuck in this HUGE body with so many med problems. WELL I WAS IN FOR A BIG SURPRISE.

I went to the office and asked the Doc for a referral. She looked at me like I was crazy stating "Ive never had anybody ask me for such a thing" and "why would I want to go to such drastic extremes to lose weight"

and there medical group requires 12 months of supervised weight loss to even consider a referral. I just started to sob. I felt like someone and just CRUSHED MY SPIRIT.

so now I am going to switch to another group that requires 6months of dieting. I have a BMI of 36, but hypertension, pre diabetic, severe carpal tunnel, swollen knees, hyperlipidemia etc. All because of weight. I have lost and regained over 500lbs in 20 years.

I truelly believe I will end up dead in my 60's if I dont' lose and maintain wt loss soon.

ANY ADVISE IS WELCOMED

[taylormomto6 0]

I understand your frustration! You are doing the right thing by changing medical groups. I would be sure to choose a new PCP that is supportive of WLS. Be sure and go to every appointment for your 6 month diet. Don't give them any excuses to deny.

Good Luck!!

Cindy T