Preferred IPA (Anthem Blue Cross) DENIED

[Sumaire 75]

Got their letter today denying my surgery, saying that my current surgeon doesn't do surgeries at the hospital to which I am "capitated" (gawd, but I loathe that word).

Funny, but they've been approving my monthly visits to my surgeon since last August, a surgeon THEY assigned me to when this whole thing first started in earnest. Now they're saying No, because he doesn't practice at a specific hospital.

They sent me a referral to a DIFFERENT surgeon, and lo and behold, when I told the lady on the phone at that office what the denial letter said, she told me that this new surgeon doesn't practice at that hospital, either.

WHAT THE HELL ARE THESE JACKASSES TRYING TO PULL???? This is <insert really nasty expletive here> and I'm tired of the games.

They've picked the wrong ridiculously fat lady to screw with, and I've got a call in to Anthem Blue Cross' appeals department about this. I also mentioned to the nice lady at ABC that Preferred IPA had denied every surgery request for other patients that my preferred (see what I did there?) surgeon has sent them since this last January. The lady at ABC was nonplussed when she heard what's been going on.

We'll see what happens, but I'm more than a little hot under the collar about all of this mess.

Thanks for listening.

[Sumaire 75]

And at this point, my GP's office is submitting a modified request specifying that the surgeon chosen actually has privileges at the hospital to which I am capitated.

[CrissyCakes 110]

And at this point, my GP's office is submitting a modified request specifying that the surgeon chosen actually has privileges at the hospital to which I am capitated.

Have they tried getting an auth for the facility? I get why it was denied, but it should be an easy fix.

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[Lenoralogan@yhoo.com 13]

Yes I agree with you this should be a easy fix. I think these insurance companies don't want to approve these surgery. I guess they really don't know what they're doing

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[CrissyCakes 110]

Yes I agree with you this should be a easy fix. I think these insurance companies don't want to approve these surgery. I guess they really don't know what they're doing

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It's really on the Dr and his office. They should know where and what is accepted for each of their patients. Why submit an auth knowing you practice there, but you aren't credentialed at the site to perform her and surgery. He'd get paid but not the facility. My insurance approved less than 48 hours.

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[Ele marie 92]

I know 6 people who had the surgery through welfare medical. This is absolutely not acceptable.

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[Sumaire 75]

The insurance company's response to the doctor's staff about this was that it wasn't the company job to send me to a doctor who had privileges at the hospital to which I am capitated.

THEY sent me this particular doctor. Not my GP.

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[2goldengirl 2,076]

Yes I agree with you this should be a easy fix. I think these insurance companies don't want to approve these surgery. I guess they really don't know what they're doing

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Having worked in managed care for the past twenty years, I can assure this is NOT a case of "they don't want to approve it". It's more a case of there being a difference between a doctor visit with a contracted doctor and a request for surgery at the wrong facility. Doctor visits generally don't require authorization, just a referral, and that referral is good for up to a year.

Surgery is different, it does require prior authorization.

It just really irritates me to hear stuff like this. Believe me when I tell you, we are all working way too hard to get people care they need to be playing any silly games with people. Believe it or not, a lot of us are licensed professionals, and grown-ups. You have NO idea how many rules and regulations govern what we do, and don't, do. Denying anything happens infrequently - about 1-3% of the time, actually.

Today I am working with a new bariatric client, and two different people near death from liver failure. No, neither of them were drinkers. I came here for a quick time-out between phone calls.

[Sumaire 75]

Gets better. There are no doctors who practice at Monterey Park Hospital (where Preferred IPA says I'm capitated) who accept Anthem Blue Cross.

You'd think the insurance company would know that already.

Meanwhile, Anthem Blue Cross says I'm capitated to Alhambra Hospital, which doesn't DO bariatric surgery.

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[Sumaire 75]

Well, it's resolved for now.

I've changed providers and thus doctors, aftering find a surgeon who accepts my insurance and then finding a doctor who is affiliated with the same insurance provider.

It turns out that Monterey Park Hospital doesn't even support bariatric surgery, so Preferred IPA was making a requirement that could never be fulfilled in order for me to get surgery. I'll be making a formal complaint about that, as I can't be the only person who has been affected by this deliberate stonewalling.

Hoping for a fruitful relationship with my new insurance provider.

[gina171 626]

I know 6 people who had the surgery through welfare medical. This is absolutely not acceptable.

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??????

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[Sumaire 75]

I know 6 people who had the surgery through welfare medical. This is absolutely not acceptable.

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??????

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I'm assuming that the poster feels that only people who have insurance OTHER than state-paid should have their bariatric surgery covered.

I disagree with that opinion.

[gina171 626]

I know 6 people who had the surgery through welfare medical. This is absolutely not acceptable.

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??????

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I'm assuming that the poster feels that only people who have insurance OTHER than state-paid should have their bariatric surgery covered.

I disagree with that opinion.

Yep, I agree with you....it's a lot cheaper to address the root cause of their chronic health issues than to spend a lifetime (and fortune) treating the symptoms of diabetes, hypertension, strokes, etc., etc., etc.

Not to mention it's a lot more humane.

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[Sumaire 75]

I can't until my first appointment on July 1st with my new PCP. I'll be right there, asking for my referral to the surgeon I've chosen.

Two weeks from tomorrow.

​I'm hoping it's not like when I was a kid, waiting for the next school holiday to arrive. LOL

[Shrinkinqtpi 202]

@@2goldengirl Thank you for your insight into the world behind the scenes of the insurance company. My father-in-law is a registered nurse who now works as a manager for an insurance company. It is a tough business to be in. You are appreciated.