I have Pacificare, but welcome answers from anyone!

[serenity55 15]

:confused:What is the procedure? Do you have to have the authorization from your insurance company when you go to see the surgeon, or just a referral from your primary care physician? Do you start the six months’ nutrition and weight loss after your first consult? Does your insurance pay for the presurgery testing, or does that always

come out of pocket? Help!!!

[ocbreeze4u 0]

I do not know much about Pacific Care, are you PPO or HMO? If you are HMO then you need to go throught your PCP/Gate Keeper. If you are PPO then chances are you can just be a self referral.

With my experience I thought it was best to do a Surgeon Consult first as they are very experienced with what EXACTLY you need per your insurance to get approval. I have Aetna PPO and I did that and I am glad I did. Although I had to go through two appeals it was worth it (I am on the low end of the BMI chart).

[serenity55 15]

Dawn,

Thank you very much. I'm going to my doctor with more paperwork in hand, and each time I do this I hope something will change I guess I thought I had to have a referral before I could see the surgeonbut I'm just confused.

Debbie for the fir.

[Futr littl Debi 0]

I have the PacifiCare HMO plan. When I started this (April 2007), I needed to get a referral from my PCP for a bariatric surgeon consult. PacifiCare responded with a denial of the authorization and instead referred me to their Healthy Roads program. This was a 6 month telephone support program. After 5 months of that, PacifiCare changed their requirement and no longer required the Healthy Roads program. So I went back to my PCP and she submitted another request for the referral for the bariatric surgeon consult. This time, it was approved.

I went to the consult and they told me that in order to submit for approval for PacifiCare, I needed the nutrician appointment and the psychiatric consult. The surgeon's office made those appointments for me and once I completed those, we submitted for approval. I was approved in about a week.

Overall, not a bad experience. I just needed to pay the office visit copay for the surgeon's visit and the psych visit. I will also have to pay the copay for the hospital.

Good luck to you!

[serenity55 15]

Thank you, Debi. I guess if I continue fighting it’s going to be a long road. I was hoping it wouldn’t because, when I called Pacificare a couple of months ago, they said they would pay for the surgery if it was medically necessary.

I went to my doctor’s office today, and took a letter from my personal trainer, and another letter I had written, explaining that it would be difficult to go to Fountain Valley in Orange County, which is where they wanted to send me. I also had copies of the brochure I got when I attended the seminar in June. Both my doctor and the woman who deals with authorizations weren’t encouraging as far as how they thought Pacificare will respond. Neither of them seemed to think that the physicians’ group I belong to, will send me to a hospital that is closer to me, even though they have used them before.

When I left my doctor’s office, I felt like giving up, and to tell the truth, I don’t feel a whole lot better now.

[blynn 0]

I had my consultation with the surgeon today. I also had an appointment with my PCP for blood work and EKG. Unfortunately there was a small blip on my EKG, so I have to see a cardiologist before my PCP will clear me. I have my psych evaulation on Monday. Once all the results are completed and sent to the surgeon, then it will be submitted to Pacifcare for approval. Please let me know how you are doing in the process. We can do this !!!!

[serenity55 15]

Hi Blynn,

I went to my primary care doc and she wasn’t very encouraging. I guess it’s the provider, the physicians’ group that’s hanging me up. My doctor seems to feel that there’s no way this group will send me anywhere that’s not in network. The only surgeon who they would refer me to is in Fountain Valley. Even if I switched groups, they still might, according to my doctor, try to send me there.

Pacificare has always been great for me, but this is really depressing me, and I don’t know if I want to fight with these people. My personal trainer has sent a note along with the letter I wrote explaining why I don’t want to go to Fountain Valley

I think it’s great that your doctor wrote a referral for you to go to the surgeon. Is Pacificare paying for all your tests? Let me know what happens with the result of your cardiology appointment.

I had an appointment with a cardiologist a couple of weeks ago, because I was diagnosed with a heart murmur when I was a kid, and I have something called pulmonary stenosis. They did an EKG, an echocardiogram, and the stress test. The doctor says it looks good, but he hadn’t sent anything to my primary care doctor, though he said he would. My doctor says that office is pretty slow about sending information.

Anyway, I hope you have good luck. It sounds like you’re on your way. Please keep me posted on your progress. I’m rooting for ya!

[Futr littl Debi 0]

Hi Serenity,

I'm sorry that Fountain Valley is quite a ways away for you. I live in Fountain Valley and my doctor's group sent me to Dr. Leport's office. That's probably the group PacifiCare is trying to send you to as well. That whole office has been wonderful. I really like them. So take heart, even if you don't win the argument with PacifiCare about not driving so far, at least they say it will be covered. And they do bunch up the pre-op appointments for you, so you won't have to drive down here constantly. Just think, some people have to fly to different states or countries to get this done. We can count ourselves among the lucky ones.:thumbup:

[serenity55 15]

Hi Debi,

Yes, Pacificare--well, the physicians' group did want to send me to Dr. LePort. But I don't drive, and I don't feel comfortable asking anyone to drive me that far, so I really hope that they will change their minds. It is good to know, though that the office is a good one. good luck to you, and let me know how you're doing.

Debbie

Edited July 7, 2008 by serenity55