Kaiser, Not fat enough?! Insurance fiascos

[SugarFerret 0]

So, I have Kaiser Permanente in Northern California and Southern California, I guess it's the same but just mentioning both because I found out they consider themselves two things for some reason. After being very overweight for at least 6 years and generally overweight for at least 12 years...and doing everything from working out daily to diets to Weight Watchers to voodoo (j/k but almost lol), I decided that the Lap Band is what I wanted to pursue as an option.

WELL, Kaiser doesn't seem to like to pay for this procedure. Which is fine, it is a radical decision and wouldn't want anyone to just say, "OKAY fine we'll do it!" without asking any questions. But I kind of feel jerked around.

I'm doing this nutrition/diet program, which is all well and good, but the dieticians actually were insinuating that I wasn't "fat" enough to get a lap band >.< I'm 5'5, 258ish pounds, 44.6 BMI....this is off the charts as far as morbidly obese and unhealthy >.< the fact that they'd tell me I had to be "fatter" in order to qualify to get help seemed 1. rude and 2. hurtful and totally invalidating my feelings that I need a little extra help after years of doing it on my own.

I've never had an over eating problem and am vegetarian, mostly my problems are eating at the wrong times, such as right before I sleep, and my other health issues, among some of the problems: Multiple Sclerosis, hypertension and constant pain (probably a lot to do with being overweight as well as the MS). It kills me to think that because Kaiser are jerks about their extreme views of what is "fat" that they would just totally invalidate me and make me feel stupid for inquiring about other options.

I've looked up before what qualifications make someone eligible for the procedure and heck I think I meet them. Am I wrong to question what this person is saying? That I'm not "fat" enough? Or even worse, that there's nothing wrong with me even though, clearly, by health standards, and by my increasing health problems due to obesity, that I should just not pursue it?

I think more than likely they just don't want to pay for it and I have to be more aggressive, but it's a little depressing to think I have to "convince" them I need help.

[SuzanneG 1]

Insurance companies aren't in business to help us, they are in business to make money. You are right that they sound like they just don't want to pay. Most insurance companies require a BMI of 40+ which you have, plus you have co-morbidities.

Keep pushing them, if they deny you -- appeal!

You'll get there.

[SillyGoose 0]

Was it "Kaiser" that said you weren't fat enough or one person (like your doctor) that said you weren't fat enough?

I ask this because I too have Kaiser (north). And when I went to see my Doctor and mentioned weight loss surgery, her first reaction was "usually people who are 100 lbs more than you are the ones who get the surgery" I then called her on it and told her that I already found out that am "fat enough" for the surgery because my BMI was over 40. She then started fidgeting with a little paper gadget thingy (my guess, she was trying to see if I was right about my BMI). She then said that it isn't an easy process and there were a lot of hoops I had to jump through (she was trying to discourage me) but she finally said to have the nurse schedule me for the seminar.

And now I'm over halfway through the process and hoping to have surgery around the first of the year.

Keep fighting & good luck!

[Jesangel76 0]

First off, Let me start off by saying that I am so sorry that you're having to go through this insurance fiasco on top of your health issues. At 258 lbs and 5'5" and a BMI of over 40, plus MS - YOU ARE A PERFECT CANDIDATE! So Kaiser can take a long walk on a short pier! :eek:

Insurance companies will say anything to not pay for the surgery, but within reason. Kaiser is obvioiusly lying to you, which seem illegal. As the previous responder - you have to keep at them (insurance and your doc). Your doctor's involvement is critical because they have to write letters and submit paperwork to the insurance companies in order for them to pay. If your doctor feels you're not a candidate, then you absolutely should seek out another doctor. Ask around and so some research in your area, I'm sure you're bound to find a good doctor that will care enough.

It will take time, patience and persistence, but if you keep up the fight, Kaiser will pay! :eek:

Best of luck to you.

[SugarFerret 0]

It was a dietician who said this, and it felt like the doctor was just humoring me when I discussed this with her, but on a positive I know that I started the ball rolling. I'm glad I'm not the only who thinks Kaiser is a bunch of jacknuts >.< I'll definately keep at it, I'm glad I have support for this, because honestly, the doctors/inxurance are so discouraging of anything lol. Thank you all for being so positive, I was almost afraid I was going to get negative feedback :X I've been so used to it lately lol >.<

[Minxz 0]

First.. Where are you. The Kaiser program appears to be vastly different from Northern to Southern California.

I live in Northern Cali and am going through the steps for Lapband with Kaiser I have a BMI of 41.

I have read here that Southern Ca requires a BMI of 50+ to be approved but they to offer the surgery.

Here are a couple links to Kaiser threads

http://www.lapbandtalk.com/f18/kaiser-permanente-insurance-66458/

http://www.lapbandtalk.com/f11/kaiser-fremont-78794/

http://www.lapbandtalk.com/f8/kaiser-southern-california-74212/

[heartfire 4]

First of all, Kaiser is not full of a bunch of jacknuts. Second, you ARE fully qualified by your BMI alone and your dietitian doesn't know what she is talking about. Third, your PCP works for you and if you want her to refer you to the seminar to get going, then ask her to have her nurse schedule you.

I was banded by Kaiser North on August 25th, a full 6 months before I even thought I might start to expect a surgery date. Every single person I have dealt with throughout the entire system has been most helpful and kind. I've even been educating those along the way who had no idea Kaiser was even banding or what it entailed (the band).

I understand you're angry. BUT to lump all of Kaiser together in one pot is a bit much. It IS a long process. It's meant to be in order to weed out those who aren't serious and thinking they're in for a "quick fix." Kaiser fully pays for the entire surgery. The only money I've put out are the seminar/class fee ($100) and my co-pays for my appts. and surgery (all of $15 for each, including the surgery!). Kaiser had another problem in that as soon as it was discovered by the general population that they were paying in full for the surgery, they had a TON of people jumping on the Kaiser bandwagon to get surgery. They've since made some changes, one is that you now have to be a Kaiser member for a year before they'll even talk to you about it, second is the classes and appts and diet you have to do before surgery.

The ONLY people who determine if you ware qualified for surgery are the Bariatric Surgeons themselves (although the pysch does determine if you're mentally fit for surgery). They look at your file and go from there.

Please feel free to ask any questions you might have about the process. I went through the Fresno program so I'm most familiar with that one. But please, ask away! And DON'T GIVE UP!!! Jump through your hoops, see whom you have to see and do what you need to do in order to go through the system. Best wishes!!

[SugarFerret 0]

Okay the first people I talked to were the Southern Cali Kaiser people, and they were telling me I needed 50 BMI but would put me in the classes anyway since my other problems, I've since had to switch to Northern Cali Kaiser.

I don't like Kaiser, I'm sorry if other people like Kaiser, and not everyone there totally sucks, but I've had REALLY bad experiences with that company, totally unrelated to the recent issues. It's fine that other people love Kaiser, that's cool. But I don't, just my opinion. (BTW. Some of the people who work there are fine, just like any group of people, but the people I did deal with were indeed, jacknuts :smile:)

Lol and I'm not angry, just discouraged. I've dealt with being overweight for a long time, and to just be told I'm not qualified to complain and try to fix it is kind of....well, not okay. Wouldn't anyone be a little discouraged if someone told them they were fine even though they were not lol?

My only concern now is that I won't be able to be there in California enough for them to consider me serious enough, since I live in both Texas and California, and going to school full time in Texas. But that's a totally different problem and not really having to do with this forum.

Thank you for helping me feel more validated on this subject, I feel a lot better about this and will be more confident when dealing with the system.

[April410 0]

I have to agree with one of the previous posters who said that insurance companies are not in the business of helping us.....they are in the business of making money......(and not spending it!).....

I don't know anything about Kaiser.....but I am sure they are not the only insurance company who will initially deny a request for lapband or bypass surgery. A lot of companies prefer that you try to diet and lose weight naturally (of course MY insurance did not pay for the nutritionist!!!! Cost me $500).....It is also not uncommon to be turned down the first time around. I was. My doctor's office filed an appeal and I finally got approved last week...and hope to have surgery in late December or early January.

I have also heard from friends that their PCP's or regular MD's are just not educated on the benefits and success of LapBand.....and they haul out the same old story.....diet, exercise etc........As if we haven't tried that 100 times already! (what kills me is these doctors are usually Doogie Housers who are like 12! .... and probably weigh 120lbs soaking wet.

Those of us who have been around a few years and have tried all the diets and have had successes and failures along the way know that dieting alone is not enough. I know that LapBand is not a "magic bullet"......I still have to put effort into eating healthy and getting some exercise, but what I need is a tool to help me.....something that will "force" me to eat less....and hopefully allow me to feel less hungry all the time.

By all means.....appeal! The more noise you make, the better chance you have of getting approval. With your weight/height I would say you definitely qualify!

Good luck!

[mollymai 0]

Was it "Kaiser" that said you weren't fat enough or one person (like your doctor) that said you weren't fat enough?

I ask this because I too have Kaiser (north). And when I went to see my Doctor and mentioned weight loss surgery, her first reaction was "usually people who are 100 lbs more than you are the ones who get the surgery" I then called her on it and told her that I already found out that am "fat enough" for the surgery because my BMI was over 40. She then started fidgeting with a little paper gadget thingy (my guess, she was trying to see if I was right about my BMI). She then said that it isn't an easy process and there were a lot of hoops I had to jump through (she was trying to discourage me) but she finally said to have the nurse schedule me for the seminar.

And now I'm over halfway through the process and hoping to have surgery around the first of the year.

Keep fighting & good luck!

Is there a long process through Kaiser? I have Kaiser Medi-cal and would like to get some info before I go to the orientation. do not have a date yet for that.

[SillyGoose 0]

Is there a long process through Kaiser? I have Kaiser Medi-cal and would like to get some info before I go to the orientation. do not have a date yet for that.

Check out the post below by Minxz - there are a few links to other Kaiser threads. As you will find, every Kaiser seems to be a little different, but usually, yes there seems to be some sort of process through each one..... Personally, I'm finding that the process is moving by quickly.

Good luck to you!

First.. Where are you. The Kaiser program appears to be vastly different from Northern to Southern California.

I live in Northern Cali and am going through the steps for Lapband with Kaiser I have a BMI of 41.

I have read here that Southern Ca requires a BMI of 50+ to be approved but they to offer the surgery.

Here are a couple links to Kaiser threads

http://www.lapbandtalk.com/f18/kaiser-permanente-insurance-66458/

http://www.lapbandtalk.com/f11/kaiser-fremont-78794/

http://www.lapbandtalk.com/f8/kaiser-southern-california-74212/

[volcano lady 0]

I am in the Kaiser program in Hawaii. From my understanding, the dietitian will put in a report (after 4 visits), as well as reports from a mental health therapist and physical therapist and my doctor. After I have jumped the hoops, there will be a "presentation" including the surgeons. It is THEN it will be determined if I am eligible. One person does not make the decision.

This is the scary part, tho. What if I have lost too much weight from the regimen I'm following and they feel I can do it on my own with more determination on my part, although they say that won't happen?

My advice to GirlNextDoor is to talk with your doc. The dietitian is out of line. As far as insurance companies saving money, I hope they realize the amount they will save in the long run when our health improves.:thumbup:

[itzgigi 0]

Hi I'm 5'4 and 205 but have high blood pressure too. I have Blue Cross the covered no problem. Call the weight loss centers thats where I had my surgery they said if insurance companies deny it that file appeals and have so far won most of them. I didn't think I would qualify I was shocked my band surgery was on 10/17 still recovering but very happy I made the choice to do it. Good Luck

[momcof3 1]

I had lapband at Kaiser Richmond (Northern Calif) on Aug. 26 and I did not have any problems with the staff or the program. My BMI was 42 when I started on May 9 - but all that was required was a referral from my PCP and a BMI of 40 - or 35 if you had co-morbidities - although I didn't have any. I started with orientation on May 9 and had surgery Aug 26. All of my appointments and surgery were my $15 co-pay.

I don't think the process is any different if you are on Medi-Cal - however your co-pays may be different - you would need to check with Member Services.

[Jesangel76 0]

Okay the first people I talked to were the Southern Cali Kaiser people, and they were telling me I needed 50 BMI but would put me in the classes anyway since my other problems, I've since had to switch to Northern Cali Kaiser.

I don't like Kaiser, I'm sorry if other people like Kaiser, and not everyone there totally sucks, but I've had REALLY bad experiences with that company, totally unrelated to the recent issues. It's fine that other people love Kaiser, that's cool. But I don't, just my opinion. (BTW. Some of the people who work there are fine, just like any group of people, but the people I did deal with were indeed, jacknuts :thumbup:)

Lol and I'm not angry, just discouraged. I've dealt with being overweight for a long time, and to just be told I'm not qualified to complain and try to fix it is kind of....well, not okay. Wouldn't anyone be a little discouraged if someone told them they were fine even though they were not lol?

My only concern now is that I won't be able to be there in California enough for them to consider me serious enough, since I live in both Texas and California, and going to school full time in Texas. But that's a totally different problem and not really having to do with this forum.

Thank you for helping me feel more validated on this subject, I feel a lot better about this and will be more confident when dealing with the system.

Sugarferret - whatever you do, don't give up and please do not get discouraged. I have Aetna and I've had to jump through so many hoops that I"m surprised I haven't reached my goal weight! But I just got my call on Friday that I've been approved and my surgery date will be on 11/24. It pays to be persistent!

Best of luck to you and please keep us posted!