Getting there: March 2005-2006
The following narrative comes from my profile on ObesityHelp.com, where I participate in an invaluable online discussion group devoted to what folks there familiarly call "the DS". It's one long post here because that's how the formatting ended up when I imported it, but it proceeds chronologically, from March 2005 to March 2006 -- pre-op to post-op.
My Pre-Op Journey
Introduction
As I write this in March 2005, I'm 44, 5'6", and have been morbidly obese since my teens, despite frequent and sustained efforts to lose weight (I can lose it but I can't keep it off!) Given the increasing severity of my chronic health problems of Type II diabetes, hypertension, and high cholesterol, I've decided to seek surgery -- specifically the duodenal switch. Initially I was entirely opposed to weight loss surgery of any kind -- without knowing anything about any of its forms, I might add. After doing extensive research, however, I believe the duodenal switch represents my best chance at a healthier life.
I'm a college professor, married, and while my husband and I have no children, we're fond of our share of cats - lol. We have two at a time and also care for those stray passers-by who travel through our yard and sometime elect to stay for a while.
MARCH 9, 2005
I put the wheels in motion on March 1, asking my (wonderful) PCP to support me in my quest for WLS, which she's doing. My major lab work is done, and I just had my cardiac stress test this morning: no arrhythmia or ischemia and my blood pressure is normal at rest (on three meds, though, thanks). It shoots up with any activity -- are we surprised? We are not.
My medical group wants me to go in network to Stanford, but it doesn't offer DS, so I've requested an out-of-network referral for a consultation with Dr. Rabkin. It was denied, saying that WLS services are offered in network. "Not the DS," I replied (in a 4-page letter with 32 footnotes documenting the pros of DS over RNY and gastric band, particularly for my set of co-morbidities), "so Stanford won't be able to consult with me on all options." So we'll see what my medical group comes back at me with. I'll call on Friday. If necessary, I'll change medical groups, but I really like my PCP, so I don't want to have to do that. Fortunately I know that my insurance -- HealthNet HMO -- does *not* exclude DS, and that's encouraging.
In the meantime, I'm going to a monthly orientation in San Francisco this evening for Dr. Rabkin's practice and looking forward to meeting the patient coordinator, with whom I've exchanged emails.
Slow and steady wins the race, I say. I'm hoping for a smooth referral and approval process for the DS but not expecting it, so I'm doing all I can to prepare myself, emotionally and physically, with information, research, and back-up data. It's very helpful to read everyone's stories and journeys as I begin my own.
MARCH 11, 2005
I went to the informational seminar for the Drs. Rabkin and their Pacific Laparoscopy practice in San Francisco and was very glad I did. They seem very organized, complete with greeters at St. Mary's Hospital, a room for the one-hour lecture/Q&A session for newcomers (just three people, including me on Wednesday), and then a much larger pre/post-op meeting of Rabkins' patients, which I stayed for.
I realize that the first part of the meeting was both informational and a bit of implicit marketing, but in fact, I really liked that the surgeons themselves are there to provide information at such meetings. Both brothers (Drs. John and Robert Rabkin) also stayed through the pre/post-op meetings, and the therapist they refer people to was there as well ... it really seemed like a together, caring group of people who are in this for the good of others as well as to make a living, and I appreciated that.
It was good for me to see folks pre- and post-op as well, particularly at various stages out from their surgeries. Even those in the first couple of months following their surgeries were very glad they'd had the procedures done. Yes, they looked tired and grey, but they were on their way to a new life, and the tales of others further down the road were encouraging to both them and me.
Yesterday I called my medical group to inquire about the status of my appeal for an out-of-network referral to the Rabkins, and I was told that they never received my fax from three days earlier. Sigh. Lesson #1: pay attention to my inner gut feeling and follow up earlier rather than later. I refaxed it yesterday afternoon and called to check on it this morning -- yes, they received the second fax. Good. Now I'll follow up again with them on Wednesday of next week.
MARCH 13, 2005
As a Type II diabetic (one of the reasons I'm wanting this surgery), I'm stressing about my blood sugars being out of control right now (200s-300s). This, despite oral meds. I suspect I'm headed toward insulin; my tall, slender mother was insulin-dependent and didn't have weight to complicate the issues.
Anyway, my PCP is referring me to an endocrinologist, which is good; I know that my blood sugars will need to be under control in order to have WLS, so that's something I can actively work on as I wait for my medical group to approve or decline my request for an out-of-network surgeon and, quite possibly, select a new medical group and doctor that *will* refer me to whom I want.
I'm trying to stay focused, work on the things where I can make a difference, and know that each step, however small and however long it lasts, takes me one step closer to better health in the long run.
"Rose Finfare", a beautiful watercolor I bought from Portland artist Liz Walker
Click Here For Artwork by Liz Walker
MARCH 14, 2005
Wow. I just called to check on the status of my request (and my PCP's request) for my medical group to refer me out of network for a consultation with Dr. Rabkin in San Francisco (as he's my first choice AND there's no one offering DS within my medical group AND my insurance does not exclude DS).
The letter must have packed a wallop, as they're taking it before a doctor to review today and before a committee tomorrow, if s/he can't make a decision. Hmm. Of course, my letter *did* have 32 footnotes to medical literature -- but all of this is simply over an initial *consult*, not the surgery itself. It's a necessary step, however, as I have Health Net HMO, and in order for insurance to kick in, I have to be referred by my PCP (who totally supports this).
Well, I'll give them today (for the doctor) and (tormorrow) for the committee, and then switch medical groups if necesssary. I'd rather not, though, so keep your fingers crossed for me!
MARCH 17, 2005 - Happy St. Patrick's Day
I just received a form in the mail from my medical group, indicating that they'd ultimately forwarded my appeal to Health Net itself, along with my PCP's report and a copy of their denial of an out-of-network consult.
So -- the issue has now gone to the Big Boys (i.e., my actual insurance company). At first I was stressed because I didn't want it to count as one of my available appeals that I might need down the road for the surgery itself -- but hey, *I* didn't forward the request to Health Net and it was clearly addressed to my medical group, so I doubt seriously that a good case could be made for it as using up one of my own appeals (I need to find out how many appeals I'm allowed -- I may simply be borrowing trouble, but forewarned is forearmed).
Since I'm a control freak, it's hard to let this one go for the next few days until the materials reach Health Net (I just checked -- they haven't yet). I feel as if I should be DOING something else, but of course, I need to pace myself and be balanced about this. Heaven knows there are probably plenty of future battles to fight in the future, so I should just enjoy the lull and take things as they come!
(I'm not very good at that!)
MARCH 22, 2005
Well, my medical group forwarded my appeal to them for an out-of-network referral for an initial consult with Dr. Rabkin of Pacific Laprascopy to my insurer, Health Net HMO, because they didn't feel they could evaluate the information I included, arguing for a surgeon who does DS -- and wouldn't you know it, Health Net hasn't received any such package from them.
Gotta love the U.S. Postal System (not! -- of course, *I* would have sent it by certified mail and all that) and the red-tape run-around.
So I'll give it a couple of more days to see if the packet turns up (but it shouldn't take almost two weeks for mail to go between northern and southern California) and then ask my medical group to compile its packet again.
GRRR.
Purple Alyssum from our garden
APRIL 27, 2005
Well, my insurer Health Net HMO did get the packet eventually. They took a month to deny the appeal but offered to refer me to three possible alternate surgeons for an initial consult.
Two of them turn out not to contract with HMOs to do any WLS (gosh, you'd think my HMO might have found that out for themselves). The remaining surgeon on their list was Ara Kashishian, 4 hours away. Did my research, figured he was a pretty good option, and although I wasn't wild about dealing with distance surgery, called for the referral number my HMO said they would give me. While I was on the phone, I asked if there would be reimbursement involved for things like hotels and care post-op, since they were referring me to someone out of the area.
"Oh, this is just for an initial consult." (I know that, but it seems like a logical question to ask for the future, right?) "The actual surgery would have to be done within your medical group."
"Um, see, that's what started this -- there *isn't* anyone in my medical group who does bariatric surgery; Stanford does only two kinds and therefore isn't in a position to pass on which WLS the best for me; the DS is not excluded by Health Net HMO and should therefore be an option for me if deemed one by an expert, so ... it makes sense to refer me to a surgeon who 1) does multiple kinds of WLS; 2) whom you'll approve to do the surgery, assuming I meed the criteria for medical necessity."
Oh.
To be fair, he seemed to get it then, said he'd have to go back to his nurse (advisor, I guess), and he'd get back to me. I called today to follow up and left a voice-mail. I called again at the end of the day, got him, and he promised me an answer tomnorrow.
Believe me, I write excellent, detailed, reference-laden letters -- so they're just not getting it because they don't *want* to get it. All of this over a frickin' initial consult? Figure it out!
We'll see what tomorrow brings!
MAY 1,2005
Ohmygod. I just got a call from Health Net HMO (*HMO,* mind you), informing me that, in fact, they will refer me for an initial *out of network* consult with Dr. Keshishian in Delano, CA. Provided that he recommends surgery and I meet the criteria, "we'll work something out with your medical group so that you can have the surgery with him, and Health Net will cover it." OMG. My jaw dropped!!!!
They weren't willing to refer me to the Rabkins, who are infinitely nearer, because, from their perspective, it was a double whammy that they belonged neither to my medical group or Health Net HMO. However, since Keshishian does belong to Health Net HMO, they're willing to refer me out of my medical group to him. "The procedure you're seeking [DS] is very specialized, so it took us a while to figure this out; we hoped the distance would be something you can deal with."
I tell you once again, my mouth dropped open. I was JUST in the process of putting together an appeal to California Department of Managed Care -- but given the research I've done on Keshishian recently and the patients of his that I've had contact with, I'm willing to go with this option. The distance will be a hassle, he does mostly open DS ... but he's done over 900 surgeries with only one death, and I think I'm probably damn lucky to be able to have him as a "fall-back" option. ESPECIALLY given that I've got an HMO, not a PP0. I still expect some hassles along the way (I'm keeping a written record of this phone call, as future back-up), but for now this means I can move forward.
The Health Net rep was very sweet, said he'd try to call me back today with an authorization number for the consult but, either way, he'd call as soon as it was generated and mail me a copy as well. "I just wanted to get all my ducks in a row before I called you back," said he, "and I was hoping that you'd see this as good news."
OMG, I'm still in shock. I think I have to leave the house and just get rid of some of this energy!
MAY 9, 2005
Nine days later, the shock has worn off, and frustration has set in again: Keshishian's office and Health Net aren't connecting: K's office needs to verify the authorization number and benefits, the Grievances and Appeals rep isn't calling them back, and so things have stalled for the moment. I'm so fucking frustrated: I just want to keep moving forward for an initial consult at the very LEAST -- I have insurance that covers the DS, and yet it's taken me over *** 2 months *** to work through to this point, which feels like NO WHERE. I know I'm lucky to have insurance at all, coverage of the DS specifically and all that, but honestly this just makes me want to scream. This is a function of having an HMO and being part of "managed care." MISmanaged care, is more like it.
In my head I'm freaking out about scheduling. If I can't get this done this summer, I'll have to wait until winter break in December, and I don't trust insurance co's enough *to* wait: policies can change, and so forth. I'm thinking about backing out of one of my teaching commitments come fall to lighten my schedule and allow me to have the surgery. I'd feel bad about that and it wouldn't be cool, but my health has absolutely got to come first.
Ah well, no use borrowing trouble until I'm dealing with cold, hard dates.
Taking a deep breath and hoping things resolve themselves today, at least as far as the initial consult goes.
*** Later ***
YAY! Only a few hours later, and things have worked out for an initial consult: May 19 in Delano!!! Dr. K's office finally connected with Health Net HMO, got the authorization for the referral, checked the coverage for exclusions, and gave me the green light.
Dr. K's office said to plan on a 9 a.m. - 3 p.m. stint with them that day, so since I live 4 hours away I'll drive down the night before after work. Fortunately for me, I like long car drives -- just me and my iPod. Never mind that this is happening in the midst of end-of-semester madness and I have many grad students' theses and papers to read. I'll take what I can get!
Yippee!! Moving forward!
Calla Lily from our garden
MAY 18, 2005
It's just past 9 p.m. and I made it safely to Delano, CA for my consult with Keshishian tomorrow! I'm at the Comfort Inn because the Best Western was full up this evening, and it's fine. The room has air conditioning, a hip-high fridge, a microwave, a very accessible bathtub/shower (you can tell that I'm checking it out for a possible post-op recovery base if I do, indeed, get switched with Keshishian -- but before I leave here tomorrow afternoon, I'll check out a sample room at the Best Western as well), along with a hair dryer and coffee maker. I hear both the Comfort Inn and Best Western will help arrange for a recliner as well.
There's a K-Mart with a pharmacy on the corner, plenty of fast food and sit-down restaurants in the immediate vicinity for support people, and there's a TV with oodles of cable channels in the room for a post-op me. My cell phone gets good reception here, so that's good. Going to see if there's a nearby mall or something where I might walk in air-conditioned comfort in the summer as I recover ... it's already heating up in central CA. And, as you can perhaps deduce from this post, the Comfort Inn offers free wireless Internet access -- a major plus for me!
I'm nervous about tomorrow, but I have a very good friend who was switched (by the Rabkins, not Keshishian) about four years ago, and she told me to call her during a break during tomorrow's teaching/meeting sessions if I start to get overwhelmed or want to bounce anything off of her, so that's cool. I've been taking care of her periodically as she's recovered from plastic/reconstructive surgery (tummy tuck, brachioplasty), and there's a chance that she may be available as a co-support person with my husband (she's already offered and I'd feel totally comfortable with her ... just depends on scheduling). But I'm getting ahead of the game here.
Keshishian's office called me on my cell as I was en route to Delano to confirm and to ask if I could show up half an hour earlier than planned tomorrow morning (8:30 a.m. -- yes, of course). I've obviously brought my laptop with me, so I'm going to spend the rest of the evening now going through my files and compiling a list of questions for tomorrow from the notes I've made over the last five months.
Taking deep breaths to calm the nerves ... you work hard to get something (took two appeals to get this referral), and when it comes, WHAM! Good heavens, if I'm like this over the consult, what will I be like when it comes to the actual surgery?!
**********
One more (sobering) thought before bed ... since my last HbAIC result was very poor (11.7), I'm anticipating that I'll probably need to get that down around 8 or so, perhaps lower, before a surgeon will want to operate on me. My daily readings have been better since my meds were upped, but based on some research I've done, I think I'm going to have to get religion on the very low-carb front in order to keep those readings at a consistently good level to give me me a good HbA1C reading (it reflects a three-month period).
So I'm actually thinking that the summer will need to be devoted to *that* project. That means that my next window of opportunity for the DS wouldn't be until December (I'm a college professor and would have to schedule surgery during breaks between terms).
I needed to write this out here because I realized I was getting *way* ahead of myself in my post (above). Ironically, my blood sugar will probably have to come down before I can have the surgery that will hopefully, in itself, lower it further -- but I know that this is about coming through the surgery with as few complications and as much safety as possible. I'll chafe at the delay, assuming there may be one, but I'll have to keep in mind that it will force me to focus on eating similarly to the way I'll need to be eating post-op, and therefore it will serve a two-fold purpose: it will lower my glucose levels *and* give me some strict practice in DS-friendly eating.
I think that actually *hearing* this tomorrow (as I'm anticipating I will during my consult) will be hard for me, so I'm writing this here so that I can go back to it as a way of talking myself through any disappointment and staying focused on the long-term goal of better health. If there is a delay, I can use the time to continue to gqther old health records and get as healthy as possible *before* surgery. (Never mind that I've gained about 25 pounds since my diabetes meds -- orals -- were upped and now *hate* the feel of an added fat roll on my body. I'll have to deal because there's no use going into this surgery if the odds of successful recovery aren't totally on my side.)
Okay, I'm signing off for the evening and will report back on Friday after i get back from Delano. If my suspicions are correct about all of this, then I may need some comforting but I'll try not to whine too much!
Initial Consult
MAY 22, 2005
Bottom line: everything went GREAT! I thought it would be a kind of cattle call education class, but no, I was alone, personally greeted by the staff, and made to feel very welcome. With approval, I noted the MO and SMO-friendly armless chairs in the waiting room, the practical tactfulness of the staff, the supersized Tanita scale, surrounded by a heavy-duty walker for those who might need help, etc. I watched a couple of video tapes in a comfortable room, and then Dee, an LVN and primary contact person, met with me for about an hour to discuss the history of my interest in the DS, her own experiences (she was an early patient of Dr. Keshishian's), and answer any questions. Very nice, knowledgeable woman; I think we clicked. Both she, and later Keshishian himself, allayed my fears about my blood sugar numbers: they're fine with where I'm at and the numbers are no barrier to surgery ("We've had people whose numbers are through the roof -- yours are no problem"). PHEW!
Dee let me go for lunch; we ended ahead of schedule because, as she said, "We don't often get people here for initial consults who are as well informed as you!" (So kudos to everyone here from whom I've learned so much!). I got something to eat and then checked out the bariatric wing at the hospital. Delano's a relatively small town, and the hospital is small, too, but I was impressed with the separate wing, the private rooms, the pull-out beds for support people (who can sleep in the rooms and also get three meals a day, and the friendliness of the nurses, who introduced themselves, told me they'd take great care of me, and seemed genuinely happy that I was on my way toward better health.
Then I met with Keshishian himself. A businesslike man who nevertheless seemed to have a sense of humor. Introduced himself with his first and last name only, no title, which I liked (half the time when doctors introduce themselves as "Dr. Smith," I want to reply, "How do you do? I'm Dr. McKee ..." [Ph.D., but still]). He listened well, answered my questions, was responsive, allayed my concerns on certain issues, and pronounced me a good candidate for lap DS (good!). Dr. Keshishian picked up on the fact that I was kind of bashing myself up for recent weight gain on diabetes meds (I'm now 277.5 at 5'6"), told me that sure, he figured about 50 pounds of my weight was self-inflicted (and sure enough, that's about how much I've ever been able to lose on my own), but that given my relatives with MO, some of this was the luck of the draw of genetics, and I needed to turn self-blame into praise for seeking a long-term solution. Then he joked with me, called me a "lightweight" (hey, it's all relative, I guess), and said that, despite my comorbidities of diabetes, high cholesterol, and high blood pressure, I'm currently lucky in that I have very good health and am highly functional, which will help me recover well after surgery: "Functionality going into the surgery is the greatest predictor of success after surgery."
And that was that!
I fired off an email to Dee the day before yesterday, asking about next steps, but Keshishian told me I'd receive a letter from their office next week with requests for more tests (I've already had some done), anything else they need, and they'll move ahead with insurance matters and setting a surgery date. And of course, if that letter doesn't come by midweek, I'll be calling the office to prod them respectfully but firmly along.
I need this to happen this summer, as I'm a college professor and can't take time off *except* during summers. Also, my husband's company, through whom we're insured, is planning some major layoffs, and so while we can and will continue insurance through COBRA as needed, time is still a concern for me. Dee assurred me that they'd work with my schedule to make it happen.
All in all, it went MUCH better than I thought. I was favorably impressed with the personalized attention of Dr. Keshishian's office, Dee and Keshishian himself, and the bariatric wing ... I grew up in Kaiser's system full of huge hospitals and personnel who didn't know me from a hole in the wall, so this was kind of amazing.
Crossing my fingers that this will happen this summer with no complications ...
MAY 23, 2005
I just exchanged some emails with Dr. Keshishian's office, and although they're scheduled until August for lap DSs, they're going to try to get me in on *** June 8 *** !!!!! I just saw them for an initial consult this past Thursday, they've submitted my case to Health Net for authorization, and if I have any connections at Health Net to move things along faster (they said), they encourage me to work them from my end.
It takes my breath away, but I really appreciate their effort to work me in because August may be too late for me, as I have to go back to teaching that month and wouldn't have another opportunity until *next* summer. I need to schedule a pych eval, a nutritionist's appt. and diet history, and I need a chest x-ray; fortunately, all lab work and heart stuff was done a couple of months ago.
I'l be scrambling *hard* in the next few days ... please hold good thoughts that this will pan out for the best.
MAY 24, 2005
You've all been so sweet and supportive about my *possible* date of June 8. Of course, remember, this would mean that Health Net HMO would have to 1) act in a timely fashion; 2) approve the out-of-network surgery with Dr. Keshishian (which an Appeal & Grievances agent told me they'd do, but he needs to coordinate with the authorization folks, and time is of the essence); 3) and all supporting paperwork needs to be with Dr. K's office approximately 10 days before surgery (they may leave a small amount of wiggle room on that last part, but I still need to do everything possible to get things to them ASAP).
I'm doing what I can to make this happen. As soon as I found out yesterday that June 8 was a possibility, I wrote and faxed my Appeals & Grievances agent at Health Net explaining the situation and asked for his help on the authorization process; I followed that up with a voice mail to him. I left a message with the therapist who's on both Rabkins' and Keshishian's list, explained my situation, begged him (in a dignified way of course) to squeeze me in. Rabkins' office told me he works with a nutritionist who knows about the DS, so I left another message asking him for help in scheduling that. Apparently he takes 1-2 days to return calls ... my eye's on the clock, and I'll follow up in 48 hours. I actually met him at an early orientation at the Rabkins' when I thought I'd be able to go with them, and he seemed cool. (Looked like my former therapist from Los Angeles, as a matter of fact!)
And then I spent about four hours last night, into the wee hours, constructing as detailed a diet history as possible, inserting images of weight loss charts from Weight Watchers which I kept for one year, receipts, copies of diet plans, and so forth. I turned that into a .pdf file and emailed it to Dee, the nurse practitioner.
So -- I think I've done everything I can do for the moment, though I suspect I'l be turning into a phone nag with my insurance co. after today.
I'm just staying as focused as possible on the tasks at hand; whether or not the June 8 date will be a go, I still have to provide all this information anyway, so it won't be a loss, no matter what happens.
Oh, but please keep me in your thoughts.
Abelard enjoying the garden in 2002. He lived until the ripe old age of 15.
May 25, 2005
Chest x-ray done today and should be en route to surgeon (told them it was time-sensitive).
Psych, nutrition, and final consults with PCP scheduled for tomorrow, Friday, and Saturday (all will generate letters/reports ASAP).
Called Health Net number that surgeon's office gave me, got a useless rep who said my case wasn't in the system yet, and if I wanted to know more, the surgeon's office would have to call Authorizations (they won't talk to patients directly, probably because we'll all go postal on them if it's bad news).
I got on the horn to my Appeals & Grievances rep at Health Net, who said he'd gotten my faxed letter, understood the situation and the time issue, would provide Authorizations with context and background on my case, and would call me back when he had an update.
If this goes forward for June 8, great (*better* than great, but I don't want to count on it). If it doesn't (i.e., if Health Net denies, if they're too slow), then I need to stay focused.
(Golly, despite my ever-so-sensible public attitude, I have a nervous stomach-ache! Gotta breathe deeply, keep grading graduate papers, and move from one task to the next!)
Psychological Evaluation
MAY 26, 2005
Had my psych consult today: I went with Bill Hartman, Ph..D., a psychologist who's on both the Rabkins' and Keshishian's lists, and it was just fine. He was sweet to fit me in quckly, given a *possible* surgery date of June 8 (*who* knows? I'm calling Health Net tomorrow to see where we're at with that).
Filled out two computerized evaluations concerning my emotional state and history (in which I apparently came across as wildly normal ) and then we talked for a little over an hour. It was a thoroughly pleasant experience, and he pronounced me a well-informed and all-round gold-star candidate for the DS. He clearly wants to be able to greenlight people, but he also takes the time to be pretty responsible about covering the basics and making sure folks are at least intellectually *aware* of the huge impact this surgery can make on one's life and one's relationships, even if we can never know what it's really like until we're actually switched.
He reminded me vaguely of the therapist I'd worked with for seven years in Los Angeles (and who gave me away at my wedding five years after therapy ended) so we jelled, and he promised to crank out and deliver his report to Keshishian's office tomorrow.
As for the rest, I have a quick appointment with my PCP tomorrow, which she requested (gotta remember to go over my Advanced Health Care Directive with her -- I filed it with her years ago, but we ought to review it).
I have a friend coming up for the holiday weekend (a close one whom I'll tell about having the DS during his visit -- esp. as I'm dragging him to San Francisco when I have my nutritionist consult on Saturday - lol). I'll be around tomorrow but perhaps off the boards most of Saturday and Sunday due to his visit.
MAY 29, 2005
I had an old pal of mine (Roger) visit me this weekend (we've known each other since 1983). Over dinner his first night here, I told him of my plans to have the DS, explained what it is, how it differs from other forms of WLS, and why I'd decided to have it done.
I kept scanning his face for a reaction as I was speaking, and after I finished, he said simply, "I've always known you to research things thoroughly and think things through. If you think this is the right choice for you, then I totally support you. Let me know if you need anything or if there's anything I can do for you or any way I can help -- before or after surgery."
The pal in question ... what a guy!
MAY 31, 2005
Insurance frightmare! (No suprise there, of course!)
I have Health Net HMO and appealed first to my medical group, then to Health Net HMO, for an out-of-network referral for an initial consult. Which I got -- not to the Rabkins in SF, as I'd initially requested, but to Keshishian in Delano. The Health Net Appeals & Grievances Case Coordinator told me at that time that if Keshishian recommended me for the DS, he'd coordinate between Health Net and my medical group to make sure that the DS would be approved, even though it would be out of network.
Unfortunately, Keshishian's office just called me to say that Health Net Authorizations is refusing to process their request for authorization because it didn't go through my medical group. When Dr. K's office tried the medical group, they said wouldn't touch it because they hadn't referred me to Keshishian in the first place. Now Dr. K's office is calling ME for help!
OY!!!!
Now, the only reason I'm not totally ballistic is because 1) I *knew* that this wouldn't go smoothly since what's being sought is an out-of-network authorization for surgery, which is pushing the envelope right there; 2) I just spoke to my Appeals & Grievances Case Coordinator at Health Net, who's going to pair up once again with the medical advisor he worked with to get the initial out-of-network consult authorized (she returns from vacation tomorrow). They'll approach the Medical Management office at Health Net and hopefully work things out with Authorizations ASAP.
Big "ifs," of course, esp, since time is of the essence if the target date of a June 8 surgery is to be met. But at least the Appeals & Grievances Case Coordinator wasn't back-pedaling with me, and he promised to call both me and Dr. K's office tomorrow. (Naturally, I'll call him before he calls me!)
I'm stressed (so much for the calming weekend I had), but I refuse to blow my mind yet.
My advice for all seeking approvals and authorizations: keep *excellent* written records not only of the letters and documents you send but of the phone conversations you have, the names of people you have them with, and the dates as well. I have, and if this goes through -- now or later -- it will *only* be because I established a relationship with someone higher up the food chain in Health Net than the usual customer service people, who are usually out of the information loop and know only as much background about you and your case as their computer screens tell them.
That's today's update!
Heloise, enjoying the pomegranate tree outside my study window. She died in 2005 at 5.5. years from a congenital heart problem.
JUNE 3, 2005
My surgeon's ofice just called to cancel the June 8 surgery date because neither they nor I has had a verdict from Health Net HMO yet.
They offered me June 23 but I needed to decline that. My DH has been under a lot of stress at work, and that date falls during his annual vacation during which he's able to get away for a week and go hang-gliding with his pals. He needs that trip as for his mental health as much as I need the DS for my physical health, and though he told me to take the June 23 date, I'm not going to, especially since no approval has come through yet and any date remains theoretical.
As things stand now, they've tentatively scheduled me for late July. That leaves essentially 4 weeks for recovery before I start teaching again, lightly at first and then, a month later, much more intensively. If things go well, it'll be enough time; if they don't, all bets are off anyway.
I'm a little bummed at the hurry-up-and-wait phenomenon of the past couple of weeks, resulting in nothing definitive yet, and I'm pretty tired from that and the end-of-semester work that I've just wrapped up today. On the other hand, I need to focus on the positives: no news beats bad news, and I've certainly got all my pre-op tests and consults done.
JUNE 6, 2005
Okay, so I tracked down where my case is at in Health Net HMO's system.
My case manager at Appeals & Grievances who first got me my out-of-network consult with Dr. Keshishian escalated it out of Authorizations (which wanted to drop the case from their system because it hadn't come through my medical group --> BECAUSE IT'S OUT OF NETWORK, FOLKS!) to the Medical Management office. He seemed surprised that they hadn't gotten back to me and is looking into it and is also contacting the surgeon's office to update them.
Meanwhile, my surgeon's office seems a little pissy because neither Authorizations nor my medical group would accept their request for authorization. I don't blame them for their frustration, and I know they have many, many people to process -- but I'm having to work my own insurance system with no real help from them. On the other hand, I guess I'm in a better position to do that than they are, realistically speaking.
I swear, this whole process is going to make me nuts.
Anyway, more waiting which I really, really, really, really, really SUCK at! I'm not good at compartmentalizing, and so I feel as if my life is on hold right now. I can't concentrate on anything, and I just feel crazy. I've got lots of work to do this summer, a possible family reunion to go to (or cop out of, depending on insurance verdicts and scheduling, and at this point I feel so distracted I don't even *want* to go), and friends and family whose plans depend somewhat on what *my* plans are ... and everything's up in the air. It's pressing all my control freak buttons, and I just want to rage and have a temper tantrum, as if that will fix things, make me feel better, make things OKAY. But of course, I feel as if nothing wil make this okay but an approval for the DS and a surgery date that will work for me and my family.
I know there are people out there who've been waiting years for this surgery, who travel overseas for it and self-pay, who are sicker than I am ... but none of that actually makes ne feel better. It actually makes me angrier that there are so many of us who are at the mercy of giant corporations, anonymous faceless entities, who make these life-and-death decisions without even knowing us.
So far I *have* managed to be genuinely happy for each and every person who's gotten their approval and date on the DS board, so that may indicate that I'm not a total bitch; I get nervous for myself, but I'm glad to see that others are moving forward.
AAAHHH!!!! Suspended animation -- that's what this feels like.
JUNE 7, 2005
Quietly going insane here. I made three calls today to Thushantha, my case coordinator in Appeals & Grievances at Health Net, got his voice mail each time, and no call back. There's a possibility of a June 23 surgery date that Dr. Keshishian's office will hold for me until end of day tomorrow, but if there's no insurance approval, then it's a no-go. Both my husband and I decided we'd like to try for that date, despite my husband's original vacation plans (it gives me enough recovery time before I head back to teaching, particularly if there are glitches in the surgery) but I fear it's all for nothing.
I am so powerless at this point in the process. I know I need to let go, since I *am* powerless, and that I'll find peace in the letting go, but this is pushing all my control-freak buttons, and I'm truly failing this particular Zen exercise.
JUNE 8, 2005
I've decided that giving into my control freak nature has been driving me around the bend as far as trying to MAKE the stars align for an approval and a preferred date.
I'm doing everything I can to follow up at the surgeon's office and with my insurance, often multple times a day, but let's face it, there's only a limited amount of influence that I can exert, no matter how proactive I am. Mine is a slightly strange case for my HMO, as I'm seeking approval for the DS from an out-of-network surgeon to whom one of Health Net's own Appeals & Grievances counselors referred me. If mainstream requests take a while to process, then anything out of the ordinary will probably double the time. I don't have to like it, but I shouldn't be surprised by it.
So I'm going to borrow a thought from 12 Step groups (hey, I did my time in OA, and my mother successfully stopped drinking with AA many years ago), and focus on gaining some serenity, courage, and wisdom here during this whole waiting game -- rather than on ferociously and furiously wishing/praying for Things to Go My Way.
A delay means short-term disappointment for me but also the ability to honor a promise I made to my sister to drive across the country with her to a family reunion on the east coast (originally I was even looking forward to the trip). It means I can get some much-needed work done on a collected edition of articles I'm editing and a book proposal I need to write by the end of the summer (I'm a college professor). It means I can continue to research, post, and prepare myself mentally for life post-op.
And lest anyone think I intend to sit back and go entirely with the profoundly screwed up pace of the bureaucracy of my insurance company, I do believe that I'll start looking into filing an appeal with the Department of Managed Health Care in CA by the end of this week if I can get no hard-and-fast information out of Health Net regarding the status of my case.
There are ALWAYS options -- sometimes we just have to change our perspective to find them.
California Poppies from our garden
JUNE 9, 2005
Today's good news, such as it is, is that I came downstairs to find a message on my voice mail from Thushantha, my case coordinator at Health Net, updating me on where things are at. It's the first time he's done that of his own accord, so I'm taking that as a sign that he's finally moving his tush in order to get me an approval. (I can hope.)
The update is simply that he connected with my medical group yesterday (it seems Health Net HMO and my medical group have to get on the same page, even though the surgery will be out-of network [i.e., outside my medical group]). Dr. Keshishian's office promised to fax over their authorization request to him yesterday so that he has a copy; he said that hasn't happened yet, so I emailed Arianna this morning who's in charge of that. I *so* want a resolution by end of day tomorrow (a totally arbitrary point, I realize) but I'm trying to prepare myself for another weekend in limbo.
Anyway, I need to continue letting go because that's the only thing that brings me any peace of mind. Trying to control the DS universe from where I'm sititng just makes me feel crazy and powerless, as I wrote yesterday.
JUNE 10, 2005
I've left three messages with Heath Net today, trying to get an update on where the authorization process is at, and I haven't received a call back. It's almost 4:30 pm. PST right now ... I'm not *going* to get a call back today, obviously. I just talked with a regular customer service rep there and she said verdicts on authorizations could take as long as 2 weeks. Gee, it's been almost THREE weeks. What's wrong with this picture?
I'm whipping myself up into a frenzy here again, but I get almost hysterical when I think about the unnecessary delays Health Net and my medical group have put me through. I've gained about ***30 *** pounds on diabetes meds in the last two months alone, and I can now feel that extra weight: my feet hurt, my back hurts -- in ways they've never hurt before. This surgery is not about wanting to be skinny, for God's sake -- it's about wanting my health back. Every *fucking* day makes a difference, folks: don't they get that?! Of course, I'm one of thousands of Health Net members, and no, they don't get that because to them we're anonymous names and cases that pile up in files on people's desks. It's not even that they're evil, lazy folks who work there: it's that everyone's overworked, understaffed, and the system itself is inadequate.
I hurt, I don't feel well, I'm depressed, and all I want to do is stay in bed. I'm 44 going on 80. My life is on hold; my husband's life is on hold; other people's lives are on hold until I know what's happening with this surgery. I'm as proactive as they come, and it feels as if that hasn't done me any good whatsoever.
I'm so angry -- on my behalf and those of other people who are worse off than I. There's a man named Ray who posts on the Yahoo DS discussion board: I don't know his whole story except that he's been seeking the DS for some time, isn't able to get it yet, and his health is now critical -- heading toward dialysis and all kinds of nightmares. Jesus, somebody HELP HIM!!! Give the guy a break and approve that surgery for him! WTF is *wrong* that such things can happen in what's supposed to be a relatively enlightened society?
I just want to scream.
Edvard Munch's "The Scream" (1893)
JUNE 11, 2005
Hmm, given my tantrum of yesterday (they tend to occur on Friday afternoons when I know that two more days will pass before any *hope* of further movement on my case can occur), I decided I needed to do something cautiously optimisitc. Not necessarily practical, mind you, but upbeat, though I guess what I decided upon was also practical.
I went to Long's drugstore today and added a few items to a secret surgery stash that began with the purchase a few days ago of some premoistened towelettes (for post-surgical wiping) and a stick of lip balm (both of which folks on the DS threads have suggested are critical after surgery). To that stash today I added the following: a pretty pink, white, and yellow striped gift bag in which to keep this stash, more sticks of lip balm (I always lose them anyway), disposable foam ear plugs (in case the hospital is noisy at night -- I've never stayed in one, and I'm thinking it might be hard to sleep, even if I *am* doped up), and yes, the infamous TONGS (to assist in wiping, post-surgery).
Tonight I'm going to order a snap-front dress/lounger from the Lane Bryant catalogue in which I can roam either the halls of the hospital as I walk and get my land legs again or around the motel in which I do my post-op recovery. It looks like an inexpensive, more lightweight step above a bathroom, though I can use it as such, and might be a little nore presentable as I haul my post-surgical self around in semi-public during my 10-day recovery in Delano.
If I'm not approved for the DS, these are still things I can use (even the tongs -- they're actually a kitchen utensil). But as I wait for my verdict, this makes me feel one step closer to surgery. I'm waiting to buy (or special-order, depending on the product) some nutritional supplements and vitamins, but these little items have improved my mood today -- and god knows it needed improving! lol.
JUNE 13, 2005
Oops-a-daisy! I've been fiddling around with my page here so much that I actually deleted the last couple of dyas' worth of entries -- but I figure that's okay because they were mostly vents of frustration anyway and not terribly pleasant to read. No need to recreate them!
Today's update from Health Net essentially confirms what I suspected: both they and my medical group dropped the ball three weeks ago when neither would accept the task of processing the authorization request from my surgeon, each thinking that it was the job of the other to do. Bottom line: Health Net is faxing the request to my medical group (why? it'd be an out-of-network surgery?!), and if my medical group doesn't authorize it, then my Appeals & Grievances case coordinator at Health Net will try to get Health Net to approve it.
Huh?
No, it *doesn't* seem a terribly efficient way to go about it, but I'm hoping that since Health Net authorized an out-of-network consult with my surgeon in the first place, overriding my medical group, my medical group will see the handwriting on the wall and authorize the surgery request from the same surgeon, knowing that Health Net has already seen the paperwork and is inclined to support that request.
It's pretty clear to me that both my medical group and my insurance company have messed up on the timely processing of the authorization request, so rather than pitch a fit right now, I'm going to tuck away that little factoid and bring it out again if I need to make an official appeal to California's Department of Managed Health Care.
In the meantime, I'm going to be calling my medical group this afternoon to make sure they've received the paperwork from Health Net and to ask for a time frame regarding this decision.
**********
Ohforheaven'ssake! I just spoke with my medical group. "We simply need to know from Health Net whether they want us to approve the surgery or not -- it's up to them."
So I called my case coordinator at Health Net, left him a message to that effect, said there'd been no movement on Health Net's part in three weeks, and could he update me on a time frame for a decision by the end of the day.
How hard can it be, folks, to process this request for authorization?!
JUNE 14, 2005
I just took the time to read through this entire page and realized anew how poorly Health Net has been handling this authorization request and that Thushantha, my Appeals & Grievances case coordinator there, has really screwed up: he's given me contradictory information and shown a lack of understanding of Health Net's own approvals process. Maybe he's new or something. He's a very pleasant man and I don't want to go postal on him -- but I also want results.
I think one way to address my own frustrations is to start assembling a case for California's Department of Managed Health Care -- that way it'll be there for me to file if Health Net does not authorize the surgery, and it'll keep me busy until I do hear from them.
Which isn't to say I plan to give up calling every day for an update ... it's just that I don't feel as if I'm getting straight answers any longer.
JUNE 15, 2005
Thushantha's "update" for today: he left a message this morning saying that Lorraine from my medical group called him yesterday (to tell him the same thing she told me on Monday, perhaps? i.e., that my medical group is waiting on a verdict re: authorization from Health Net?), and now he had a question for me and asked me to call him back. Which I did -- twice today -- and got only his voice mail.
This kind of slow response and turn-around is unacceptable. In addition, he simply never tells me exactly in whose hands the surgeon's authorization request actually *is* at a given point.
Yesterday I filled out the short application form for an independent medical review by California's Department of Managed Health Care, and today I started to construct a table, documenting the contact between me and my surgeon's practice, my medical group, and Health Net: date, persons involved, type of communication, content of communication. I'll finish that tomorrow, and assemble a set of attachments of the written communications. Then I think I'll need to do a separate argument for authorization of the DS for me and a cover letter laying it all out clearly.
I'd like to FedEx this packet to DMHC on Monday but I'm thinking perhaps I should wait until June 23 (which will kill me) because that will be the 30-day mark that Health Net Appeals & Grievances has to address an appeal (which is not what my surgeon's request for authorization *is,* but since I'm going through my Appeals & Grievances coordinator, it might be wise to wait until then). I'll think about it.
The need to be organized about this and the fact that I'm forcing myself to focus on assembling this packet are the only things that are keeping me from sinking into an abyss of frustration, anger, and self-pity. As long as I'm taking action, I feel more powerful.
JUNE 16, 2005
I’m weary to the bone of this authorization/appeals process after a phone call this morning with Thushantha, my Appeals & Grievances case coordinator at Health Net.
He says that my medical group needs a referral request from my PCP, requesting the duodenal switch for me by Ara Keshishian (I’m part of an HMO); the referral she requested back in March was for an initial consult, and this would be for the surgery itself. Without that, I gather that my surgeon's request for authorization for sugery can't be acted upon. And my medical group once again says that bariatric surgery is offered through Stanford’s bariatric unit -- Keshishian is out of network (Stanford doesn't offer the !@#$%^ DS -- my God, are we back to that AGAIN?).
“They’ll just turn down my PCP's request,” I told Thushantha. “That’s okay,” he said, “Because I’m opening an appeal for you today with Health Net and asking that it be assigned to me.” He said we need to go through this step so that no one can come back and say that a request for surgery did not go through my PCP and medical group and that HMO protocols were not followed.
“This is a nightmare, isn’t it?” said Thushantha sympathetically.
It is, yes. And after a call from my PCP’s office telling me that my doctor is away at a conference today and tomorrow (thus ensuring two more days of complete stalemate), I put my head down on my desk in my study at home and sobbed in frustration.
Despite my brave words toward the beginning of this profile page in which I said I knew that the road to approval might not be an easy one, I didn’t anticipate this much ineptitude. 
In my case, I don’t even think it’s that my medical group or my insurance company is stalling; I think it’s just that the red tape is so thick and the low-level customer service people in each company are so incompetent that movement on any front is extremely difficult to achieve.
Although it’s a very different scenario, this flashes me back 18 years when I was my mother’s primary caretaker at age 26 when she was terminally ill with cancer and a patient of Kaiser. I really hated the care she received there, the miscommunication or sheer lack of communication among Kaiser’s various branches and entities, and I vowed never to put myself in a similar health care situation myself.
Live and learn. The next time we have an opportunity to change insurance carriers, I’m going to make sure we get out of an HMO. (I actually thought I’d selected Health Net PPO, but I didn’t. I can't *believe* that I was so careless.)
I see time trickling away, along with my chances of getting the DS this summer, given the fact that Keshishian's office is booked out two months in advance. What the hell am I going to do? I’m a college professor, and this is the only time of year in which I have the necessary time available in which to recover. I don't work in an office or business environment in which one can request 4-6 weeks off during any time of the year. Everything seems so "unfair" -- and I hate even thinking that way because life *isn't* fair. Good god, there are people going hungry in this country and other parts of the world; there are wars and disease and poverty -- and *I'm* complaining that life is unfair? That kind of thinking is repugnant to me, but it's certainly how I'm *feeling.* I suppose I shouldn't censor my feelings, though: they're neither good nor bad in and of themselves -- they just are what they are.
I feel so demoralized and hamstrung at this point. I thought I'd be one of the lucky ones and go through this process quickly because I'm smart, articulate, can do my research, and make an excellent case for myself. But I'm *not* one of the lucky ones. I feel sad and powerless and freaked out, and I'm going to crawl back into my bed this morning and pull the blankets over my head (my tried and true response when I feel overwhelmed by depression).
I hate this so much.
**********
Went back to bed from 10:30 a.m. - 2 p.m. and cried myself into an uneasy dream date. Only good thing was that my PCP called me from the conference she's at, offered her empathy and indignation at the ridiculousness of the whole approval process, and promised to arrange to fax the requested materials to my medical group as soon as she got off the phone.
I burrowed back under the covers after her call.
JUNE 20, 2005
My medical group confirmed to me this morning that my PCP's request for the duodenal switch with Ara Keshishian has been denied because bariatric surgery is offered through Stanford’s bariatric unit -- Keshishian is out of network. Well, STANFORD DOESN'T OFFER THE !@#$% DUODENAL SWITCH, GUYS -- my God, are we back to that AGAIN?
However, the medical group faxed their denial to Health Net on Friday, so now, in theory (God willing), Health Net can override that decision, protocol having been followed. Health Net does cover the DS, and they're the ones that referred me to Keshishian in the first place, overriding my medical group's desire to send me to Stanford.
And so it goes. We’ll see if there’s movement this week … I sincerely hope all red-tape kinds of obstacles have been adequately addressed and that now we’ve moved on to dealing with the REAL issue of evaluating me as an appropriate candidate for the DS and approving Keshishian’s request for authorization.
I’m feeling much more functional today than I was in my last entry. I seem to swing wildly between total frustration and despair (when I encounter absolutely ridiculous delays and illogical protocols) and hope (when there’s forward movement). I swear to God if I get through this, I’m going to do all I can to help folks in HMOs get the DS and pass on what I’ve learned from this whole pointlessly convoluted process. There’s no reason it has to be this difficult if one meets the NIH’s guidelines for bariatric surgery and one’s insurance company covers the DS.
On another note, I realize anew that I’ve become totally obsessed with this whole authorization process, and I’ve ceased to live certain parts of my life. There’s been a very large family reunion planned for mid-July, and my sister and I were going to drive across the country together; I cancelled when it looked as if I might have a June surgery date and she found someone else to go with her. Now, of course, there’s no possibility of a June date and I’m out a cross-country drive (yes, that I actually wanted to make – lol). I can still go to the reunion if I fly, but I’m making no plans until this authorization matter is resolved, because I simply can’t think about much of anything else, and I’m on the phone daily trying to push things along.
Also, I wanted to keep this decision to have the DS private until I was approved and had a date, but I suspect that family will wonder why I’m not driving with my sister as planned, and friends are beginning to worry about my keeping a low profile over the past couple of months as I’ve been wrapped up in seeking this surgery. So I’ve made the decision to tell a few people before anything has firmed up, and the control freak in me doesn’t like doing that. However, I don’t want to alienate my friends more than I already have, and if the positions were reversed, I’d be wondering what was going on as well.
Sigh. I’m not real good at striking balances in my life; I’m sort of an extremist, an all-or-nothing person. Oh for the ability to compartmentalize!
JUNE 22, 2005
I thought I might as well try updating my profile when I’m not in the midst of a towering rage or in the depths of despair about the inanities of slogging through insurance procedures, delays, ignorant responses by low-level customer service employees, and so on. I’ve eased up a little on my daily checking on Health Net, though I’ll call tomorrow to get an update; I do believe that one has to be proactive to get anything done, but I also need to strike a balance for the sake of my sanity. (Obviously I’m not good at not obsessing, but I certainly owe it to myself to try not to!)
A lot of folks online seem to freak out about whether or not they’ll be approved; I’m freaking out over timing. I’ll get an approval one way or another, even if I have to hire a lawyer to do it. No, I’ve been worried about fitting in the surgery this summer. But you know what? I’m really going to have to accept the fact that it may not happen, and that doesn’t have to be a tragedy – it simply means I’ll have to make some choices: a) take off the fall semester which would be expensive as well as counter-productive to my career; b) delay until Christmas break. That would be six weeks, and I could do it then if I had to. I don’t want to, and I think I’d feel a lot like Starr, having to delay until August, but I could do it.
Once again I’m trying to remind myself that there are options. They may not always be my first choice, but choice I will have, one way or another, and realizing that make me feel a little less trapped and powerless (there’s that word again).
I had a pretty good day today: I got out, did some errands, enjoyed the pretty day, and read. I don’t seem to be getting much work done so far this summer, but you know, I will when I have to. My husband is away on his annual hang-gliding vacation with his pals in Idaho right now (he’s called four times today alone … kind of sweet), so I have the house and the kitties to myself, and I’m just trying to tune it, enjoy simple pleasures, and not allow myself to fall into depression (for which I’ve taken meds for the past 10 years, and mostly they work very well for me).
I even added another item to my hospital stash for when I do have the DS – a bottle of mouthwash went into my little bag. I remain hopeful!
JUNE 23, 2005
As I mentioned above, I’ve been avoiding telling most of my friends and family about the DS, mostly because I want to have things lined up and ready to go before I do tell them. However, my friend Britta was getting worried about my keeping a low profile and seeming out of sorts, so I shared a bit of what’s been happening with her. She’s a very close longtime friend, but she’s also extremely healthy, fit, and I know the idea of surgery gives her horrors, so I was nervous about telling her. But yesterday she sent me the most amazing note … I’m so lucky to have friends like her, and I need to trust in that kind of love and support a lot more than I do:
"Dear Alison,
Thanks so much for your note and for sharing with me what's going on. My god, what a horrendous strain you're under. This is big time stuff. I had no idea that the diabetes was getting so serious. I'm so sorry you have to undergo this. The surgery is scary and stressful enough, without all the awful insurance anxieties to compound your stress.
I know its all going to work out all right and you'll get the insurance and the surgery will go well -- you have the best surgeon, it sounds like, and you can't do better than that, you just have to hang in there and try if you can to access some inner peace and ride out the waves of fear and
frustration. These people will do anything to try to dodge paying for stuff, but ultimately, I think, if one is persistent, they step up to the plate.
When you do have a date, let me know, and let me know what I can do to help,prior, during or after, OK? ....
I'm thinking of you, sending my best relaxation vibes. I know it will all work out. You've thought it through and you're doing the best thing you can and you have the best doctor, and all these conditions lead to a positive end. Take some time between phone calls to breathe deeply, sit in your garden, pet your kitties, connect to whatever is god to you. You're one of the bravest people I know and you will come out soaring.
Much love,
Britta"
How amazing is that?!
JUNE 24, 2005
It's taken about a month for the wheels to get moving between my medical group (I have an HMO) and Health Net (my insurance) to even figure out how to deal with my out-of-network surgeon (Keshishian) and his request for surgery authorization -- but they seem to be turning now, albeit awkwardly.
I received a letter from Health Net today with the following demented and inept statement -- it was so nuts that it brought forth an honest grin from me:
"Health Net of California, Inc. has received a letter on June 14, 2005 from Physicians Medical Group of San Jose, which indicates a desire to initiate the grievance/appeal process. The letter indicated their desire to initiate an appeal on your behalf for coverage of services you received from Delano Surgical Group that was not authorized by them."
Okay, 1) I haven't received the DS yet, so that should be in the future tense, but whatever ... 2) my medical group turns down the requested DS but seeks permission from Health Net to approve it???? Huh??? I guess they can't approve it because it's out of their jurisdiction. But the point is, my medical group and Health Net are bumbling through a really inefficient process to try to get me an approval.
(I know what this letter is: it's written by my Appeals & Grievances Case Coordinator at Health Net who initiated the appeal himself, knowing that my medical group had turned me down. English is his second language, and so syntax and verb tense are sometimes a little off.)
The rest of the letter is a form letter, complete with the information that Health Net has 30 calendar days from the opening of the appeal (dated June 14) to resolve appeal issues --> which, assuming an approval, would put us at July 14, too late to schedule surgery for summer (Keshishian is booked up to two months in advance). Last time I went through the appeals process for an initial consult with Keshishian, Health Net basically took all 30 days to which they were entitled to process the appeal.
So -- at least I have a *time frame* to deal with. The delays make me crazy but the amorphousness of it all made me crazier!
This weekend I'm going to compile one more letter arguing for me and the DS, fax it off, and then I'm going to move forward with my life. I'm going to go to my (huge) family reunion in Connecticut in July, I'm going to start preparing my classes for the fall, I'm going to start working on an article that I've delayed writing, and I'm going to start living my life again. And when that approval comes through (and I believe it will), I'm going to schedule a date that works for both me *and* Keshishian's office. It may not be the kind of summer date that I originally wanted, but you know what? I'm going to be grateful for the opportunity to have a DS that's covered by insurance and performed by a reputable surgeon.
Already I feel more sane ... thanks to everyone who's borne with my long, griping posts thus far!
JUNE 26, 2005
My husband called this morning to tell me that he was on his way home from a week-long hang-gliding trip (he makes this trip each year), and that was the impetus I needed to start keeping my promise to myself to move on with my life and let the DS approval and scheduling time table unfold as it will.
I spent the day being domestically productive: cleaned out the fridge, restocked groceries, worked in the yard for a couple of hours (doing what it would take someone thinner probably one third of the time, but at least I was out there, enjoying the beautiful weather), and so forth. I even had a meeting with my co-editor so I can tell myself I was professionally productive as well.
I need to put the finishing touches on my letter to Health Net and various attachments, arguing for an approval for the DS, and fax it off this evening or early tomorrow morning before offices open. I have a home fax/printer/scanner but as we’ve added various technologies to my home office, I seem to have disengaged the fax portion of the machine (without meaning to, of course), so I’ve signed up for eFax which allows you to fax things from your PC or Mac. Of course, if there’s stuff I need to fax that’s not a file on my computer, I’ll have to scan it into my computer first, but hey, the scanner portion of the machine works fine, so I think it’ll all work out. This packet to Health Net will be the test case.
It feels better to have been productive today than to have napped through depression. It’s so hard to get moving, but once I do and keep myself going, I feel much better at the end of a day.
JUNE 27, 2005
What a day! I resolved to focus on the non-DS part of my life, and suddenly there’s a lot going on in that life! My husband and I went shopping for some things to pot and plant in our back yard, so it was a relatively calm morning (even though it turned out I’d tossed what I’d thought was a dead plant but what turned out to be something he’d grown from a little shoot … oops! I like the cultivated look, and he prefers eighth grade science experiment look).
But then in the afternoon multiple things happened: 1) I booked my flight for a July 13-20 trip to Connecticut to my family reunion (more on that in a moment); 2) I started getting emails from a friend/organizer of an upcoming symposium in Tokyo about an article I’m supposed to present there in November; 3) emails also started to fly among family members about various aspects of the reunion (mind you, we’re talking about 80+ people at this reunion); 4) I started getting emails from one of the universities I’m teaching at next fall (WHY ALL THIS CONCERN ABOUT THE FALL? MY BRAIN IS STILL BARELY DEALING WITH SUMMER!); 5) I received copies of a book contract in the mail for a project that a friend and I are working on together (my first book contract, even if it is only an edited collection of articles) …
And 6) I got a letter from Dr. Keshishian’s office confirming a July 26 surgery date!
For one wild moment I thought that meant I’d been approved by Health Net – but of course I knew that after all the screw-ups so far, that couldn’t be the case yet … and I was right. Still, I didn’t think that Keshishian’s office was going to hold any more dates for me until I got approved – so this was good news. Legally Health Net has to reply to my appeal by July 14, so if I’m approved, I will, indeed, be able to go ahead with surgery this summer. Big if, but still … that’s more that I thought would be possible at this point. Maybe the third date’s the charm -- I'm keeping my fingers crossed.
Now, this family reunion business …
Mystic, Connecticut
View from the house - site of family reunion 2005
My father’s side of the family has these reunions every five years (it used to be 10 but people began to get old and die, so now we have them more frequently), and originally I’d planned to drive from California to Connecticut with my oldest sister for this one. Thanks to botched insurance and scheduling issues related to the DS, I cancelled, but now I’ve decided to fly out and go to the reunion no matter what. My sister’s going to be doing most of the cooking for the huge gathering, with only a couple of meals catered, and apparently her daughter (my beloved 21-year old niece Hannah) and I are to be her faithful handmaidens, preparing potato salad for 80 (well, you get the idea). They're always held in the same place -- Mystic, Connecticut -- and as you can see from the photo above, the house where we gather is in a lovely area. It's a small 18th-century salt box house owned by our family trust (makes us sound like the Hiltons -- IF ONLY!), and it can’t begin to house us all. 
As a result, most of us will be staying in a nearby motel and coming to the house first thing each morning. Before and after the reunion proper, I’ll be staying at the house (we light it only with kerosene and Aladdin lamps), but I, too, will be in a motel during the actual reunion.
These reunions began in 1970 to celebrate my grandfather’s 80th birthday, but they’ve continued over the past 35 years and become major events that help hold together a far-flung family, with excellent attendance despite my parents’ generation being almost completely gone and the proliferation of endless cousins’ children. In fact, one of my cousin’s children just had a baby, turning me into what amounts to the current grandparent generation (don’t try to follow it – it gets too confusing even for me).
I’ve been so stressed out over insurance, approval, and appeal matters that I’m really looking forward to this change of scene. And you know, it feels GOOD to be looking forward to SOMETHING! I've had much more energy these past couple of days that I've been working hard at putting this quest for surgery in perspective and living all the other parts of my life rather than putting them on hold, and I really hope it continues -- that *I* can continue it.
Finally, I did, indeed, fax off my materials for review for Health Net to consider in my appeal, requesting the DS -- including both the Buchwald and the Hess articles, a complete diet history, a very well-argued letter based not on emotional issues but on physical health. I've done all I can do for the present, and realizing that feels good -- at least for the moment!
JUNE 28, 2005
Cool! My Appeals & Grievances case coordinator at Health Net called me this morning to tell me he’d gotten my fax yesterday with all my supporting materials for my appeal to have the DS granted – my detailed letter with footnotes to peer-reviewed literature about why the DS is better specifically for me and my particular health profile; a detailed diet and exercise history, complete with supporting spread sheets showing weight losses (and gains), receipts for Weight Watchers, and so on; and a couple of articles on the DS, namely Buchwald’s and Hess’s (thanks, Diana, for the latter). I didn’t want to overwhelm bureaucrats with articles but I also wanted them to be clear that I can do research with the best of them. I kept it entirely professional, research-based, and formal … my feeling is that goes over better with insurance companies than emotional appeals.
He told me that the packet I’d compiled was “excellent,” it would be helpful, and he was forwarding my case to “the nurse” this morning. My understanding is that it’s actually this nurse who makes the decision, and she’s the same one who got together with my case coordinator to refer me to Keshishian in the first place.
So – fingers crossed, everyone!
My energy continues to be much better – I’m telling you, hope is the best anti-depressant there is (and I should know, having been on SSRIs for 10 years – and thank God for them, too). I’m going to head out shortly to restock some bird seed, buy a few more plants to pot for our front stoop today (man, my back hurts bending over … I’m so damn OLD for 44!), and generally enjoy the beautiful weather.
You know, I don’t know what I would do without the DS community here at OH.com. I have a very close friend who had the DS four years ago, and she’s been very supportive and a wonderful resource for getting the low-down on the surgery (she actually had a really rough time and she had the best surgeons she could have had, i.e., the Rabkins), But for daily, ongoing community, support and a direct lifeline at any time of the day or night, this group has been wonderful.
JULY 4, 2005 - Happy Independence Day
No further update on the insurance front yet and I was okay with that until July dawned -- what with July 26 being held for me by Dr. Keshishian’s office, I’m hoping there will be a verdict from Health Net soon. They have until July 14, though, so I just have to remember to keep that in mind for the next couple of weeks as I wait.
In the meantime I’m beginning to look forward to my family reunion in Connecticut: the reunion itself is July 15-17 but I’ll be out there from July 13-20, staying in and around the house by the lake (see photos above). I decided I had to buy a bathing suit – you can imagine how often I appear in a bathing suit at my weight (i.e., one every five years at the family reunion!). My last bathing suit was an $8.00 job from Wal-Mart (why spend money on something I use very rarely?). It was royal blue, a traditional basic maillot bathing suit style, but its back is too low for my comfort and it had no real support, so I felt EVEN more self-conscious in it than I had anticipated This time I ordered a higher quality suit in a less traditional, slightly more flirty style. For a while I was looking only at black suits with color accents – they were supposed to be “slimming” – and then I realized that was ludicrous (er, there’s no color on God’s green earth that’s going to slim me down!), so I went bright and cheerful instead -- a kind of flame-colored suit in a hibiscus pattern and to hell with all the usual bathing suit rules!! The point is to be able to enjoy myself in the water. It has adequate back and belly coverage, breast support, lots of spandex, it'll go with my hair color -- lol -- and as for the rest of it … well, fortunately for me, my extended family is neither particularly slim nor body-conscious, so if ever there was a safe place for a fat woman to venture into the water without derision, it’ll be at this reunion! There have been fat women in my family swimming in that lake since 1930, and the earth won’t stop spinning when I do my share of it.
Picked up some sunscreen as well: I have very fair skin, and my arms and legs are especially white … on summer days I can burn within 5 minutes.
In the last couple of days I also made plans for a quick trip to Los Angeles next weekend – to see a new play! THE GHOST AND MRS. MUIR opened as a musical in North Hollywood, and since I have a chapter on that film in my dissertation (and it’s my personal favorite film in the world and has been since I was 12), I thought I’d like to see it. I’ll be going with my friend Roger, and the night before we’ll be going with a group of people to the Hollywood Bowl (that used to be a summer custom of ours when I lived in Los Angeles – didn’t ever matter what was actually on at the Bowl!) for – get this – the sing-a-long THE SOUND OF MUSIC (they’ll project it and the audience will sing along with it … I went to one at the Castro Theatre in San Francisco sometime in the last 10 years or so). I have a call into Charles, my former therapist, to see if there’s any way we can get together. If possible, we see each other when I’m in Los Angeles, though we still meet in his office. I’m getting to the point where I’d like to see him socially rather than in a therapeutic context (it’s been eight years since I was officially a client of his), but I think I’m going to have to be the one to propose that – and I’m not sure if I’m quite there yet. I don’t think he’d mind the shift, but you never know.
This afternoon I’m going to a barbecue at the house of my oldest friend in the world. He’s invited two (male) couples, one of whom I know, and his new boyfriend, whom I’ve never met, and a female friend of his whom I know slightly. He also invited my husband, of course, but my husband is a rather shy man and I figured I’d let him have some alone time at home to enjoy puttering – and fortunately my friend understood. Because I won’t be here for dinner, I’m making some boneless spare ribs in the crockpot for my husband, and some chocolate tarts (he’s a chocolate fiend) as well. As for the barbecue, I’m taking a dessert my friend assigned to me (er, does he have some control issues or WHAT?!) – chocolate buttermilk pie. I’ve never made it but it’s very easy, and it also looks like it would cause instant diabetic death! Very little flour but 6 eggs, so I suppose that’s what will bind it together.
Hopefully I'll be back before the fireworks start this evening: our cat Astro, who was a feral kitten, has been very stressed by the pre-4th fireworks so far, though Penny, our half-grown kitty who's been cosseted since birth, doesn't blink an eye at them!
Today, at least, I feel good, and I’m going to try to hang on to that feeling as I continue to wait for an insurance verdict from Health Net.
JULY 5, 2005
My car’s in the shop until tomorrow for a few minor repairs so I’m house-bound – time to do some of the domestic chores I hate like laundry and cleaning out my closet, which has become a dumping ground.
My weight’s gone up and up in recent months, thanks to diabetes meds, and so I’ve wasted money on some cheap, make-do clothing that I don’t wear in the first place. I bagged every last one of those items for Good Will, found that I still have a small range of acceptable clothing that fits me, and plenty to tide me over for a while on the way down the scale, post-DS (whenever that should occur). Makes me feel much better: it was a drag to paw through haphazardly folded, stacked, and hung clothing to find something – anything – that would fit. Now I have a much clearer sense of what’s there, what I can wear, and how to make it work for me, and the clothing in smaller sizes are there, too, hanging neatly until I’m ready for them. Fortunately most of them are in classic styles and I look forward to wearing them again.
I even organized my shoes!
JULY 6, 2005
Humph! I left my Appeals & Grievances case coordinator messages on July 1 and today, requesting an update on where things are at with my appeal – no call back. After all these months of dealing with him, I know that this means either 1) there’s no action on any front, or 2) he has no news yet …
Waiting is hard. I’m biding my time until July 14, which is the date that Heath Net owes me a verdict regarding authorization, but I leave for my trip to Connecticut on the 13th, and if I don’t know by then, I’m going to be a very unhappy, obsessed person.
Deep breath.
JULY 8, 2005
Sigh. I’m getting back into that horrible obsessive headspace again in which all I want is a frickin’ response from my insurance company. YA KNOW???? My surgeon submitted his request for authorization on May 23, neither the medical group nor my insurance company would touch it for a few weeks, then they worked out some processing procedure between the two of them, and now I’m waiting the 30 days for Health Net to process an appeal for the DS.
It does not have to be this difficult. It should never be this difficult. I’ve read of others who had Health Net HMO who had a much easier time, and the difference lies in the medical group, I do believe: although I like my PCP, the medical group itself is deeply, profoundly, mind-staggeringly stupid and has caused all kinds of delays. Now it’s Health Net’s turn – and they’re taking their sweet time about it, too. What in Christ’s name does it take?
I want an approval. I want it now. I want it now so that I have time to switch gears in my head from fighting for this surgery to preparing mentally and emotionally for it, and I need that window of time before my currently scheduled date of July 26. Not to mention the fact that if I am approved I’ll need to schedule motel rooms, my husband will need to apply for a leave from work, and so on.
Yesterday I left a message for my case coordinator, today I left a message for him … nothing. No call back. Today my message was along the lines of, “Look, between my medical group and Health Net this has taken longer than it should have, and I just want Health Net to try to understand the time situation I’m in and work with me for once!” My voice got all quivery and teary – not out of sadness, I hasten to add, but out of sheer frustration.
Tomorrow I drive down to Los Angeles to see a play and spend some time with friends, and I return on Monday. I did manage to arrange to see my former therapist on Monday before I drive home again, and that’ll be good … only of course I’d like to know that I’m approved at that point so I know where I am in my head and my time table. Health Net has until July 14 to render a decision but I leave for Connecticut and my family reunion on July 13, and it’s really going to send me around the bend if I don’t know by then.
Okay, well, I can say that all I want but it’s not going to change things, I know, so I need to concentrate on something positive: Kim Frye from the DS board here asked me to be her angel, and I thought that was very sweet! Her surgery’s on the 12th, Tuesday, and I leave for Connecticut on the 13th, as I said, so I feel bad that I’m going to be away from internet access and posting range to keep everyone updated after that point, but she said she’ll teach her husband to post as well. At least I can post that first day and I can stay in touch with her throughout the week by cell phone, so that’s good. We talked for a while last night: she’s a dynamo with two small children, seems like a strong woman, and I’m looking forward to following her progress. She’s going to be someone who absolutely makes the most of the chances that this surgery provides!
JULY 12, 2005
Having a very hard time right now: I’d hoped I’d have an insurance verdict by the time I left tomorrow for my family reunion (a week in Connecticut), and despite leaving a message today and yesterday, nada. I’ve begged and pleaded with my case coordinator to work with me on time issues, and to no avail. I’m sooo bummed out and demoralized right now.
Adding to the problem is that my very enjoyable weekend in Los Angeles included a two-hour visit with my former therapist that ended up being painful. We did therapy together for 8 years and never formally terminated in 1997 when I moved to San Francisco so that I could still call upon him from time to time. For the past couple of years we haven’t been doing therapy at all: we’d just talk and I’d update him on my life whenever I’d visit Los Angeles. This time we discussed the surgery mostly but at the end we talked about the idea that really, I was done with therapy and had been for some time, and we both accepted that. I sent him a letter this morning, formally terminating therapy and stating that I would not seek therapy with him in the future; we’d both like to find a way to be friends that would respect our past relationship, be consistent with all the ethics and guidelines of his profession, and so on. But in writing that letter this morning – which I think was right and good to do – I realized how much I’m grieving for that therapeutic relationship that we will no longer share. 16 years is a long time to have known a therapist, and my sense of loss right now is profound and extreme. I’m kind of blown away by how devastated I feel, how painful it is, how great a sense of loss I feel. Feels like a kind of death and I’m actually having my first panic attack since last December …. Hard to breath, vomiting. If I were still in Los Angeles, still his client, I’d call my therapist – but I’m not, that’s not our relationship anymore, and furthermore, the point is, I have the tools now to deal with this reaction and get through it,
What makes things worse is that my husband and I aren’t in synch right now: for whatever reason, he’s been monosyllabic about my current angst regarding insurance and surgery (mostly he’s been pretty supportive), and he had absolutely nothing to say when I expressed to him how sad I am over terminating therapy. What’s up with that?! There I am crying, reaching out to him, and he looks bored. Maybe he’s sick of the angst and the tears, maybe he feels aggravated because he’s powerless to fix what’s making me sad, but all I know is, I’d like some support and I don’t feel like I’m getting any today.
My balanced way of dealing with this right now – not! -- is to take an Ativan and possibly fix myself a DRINK, and then curl up in a ball and cry myself to sleep.
JULY 26, 2005
I just returned last night from my family reunion in Connecticut, during which I received the bad news by phone that I'd been denied the DS by Health Net. Because they have yet to get me a hard copy of the letter by fax or mail (grr -- it's been over a week), I'm not sure of the exact reason, something having to do with it not being the right form of treatment for one with a BMI of 44 (I've heard that Health Net balks at authorizing DS for those with BMIs under 50). Once I get the denial, I'll study it, but I'm definitely appealing it to California's Department of Managed Health Care, and I suspect it's time to get either Larry Slade or Gary Visio involved at this point.
Any thoughts on who's best???
So -- no surgery for me this summer (Dr. Keshishian's office had been saving a date of July 26 for me), and the next opportunity in terms of my own schedule will be December (I'm a college professor and we have a 6-week winter break then). That's okay -- it's five months in which to conduct the next phase of this fight.
Health Net does cover the DS and I meet the NIH criteria (and then some) for weight loss surgery, so part of my motivation in fighting (rather than capitulating and going out of country at this point) is that if people like me, whose insurance does not exclude the DS, *don't* fight, who will??? Of course, if I exhaust all appeals resources, then I will, indeed, consider surgery out of country.
In and around this denial, my husband and I had a huge fight by phone, in which he told me he felt I'd become extremely self-absorbed in the last seven months during which I pursued this surgery (I had to grant that that was true, as others have commented on this as well) AND that I'd given up on eating well and exercising as options -- "no discipline, no follow-through" -- so we have some stuff to work through. In the week since the (bad) fight, my thoughts are these: he's right that I did give up on healthy eating and exercise BUT not that I have no discipline and follow-through -- that stung, and it wasn't fair. Since the fight, we've begun to talk through a few of these issues, cautiously. I've agreed to try to take better care of myself *as* I seek the DS and he's said he's not ultimately opposed to my seeking the DS. We will both proceed with caution, and I hope to proceed with a little more balance (I *can* get very OCD and fixated on things, ignoring the needs of those in my orbit) but with equal energy. Best to deal with all this crap as it comes up, of course ... so there are silver linings to the delay.
So I'm combing through cases in which the denials for DS have been overturned by California's DMHC and finding hope: I'm printing out/PDFing only those cases involving *non* super-morbidly obese women (though until I get the actual denial in my hot little hands, I won't know for sure what Health Net's reasons were for denying surgery), and there are any number of cases that were overturned for folks who had lower BMIs and fewer comorbidities than I. That doesn't necessarily mean they'll overturn my denial, but it establishes precedent and shows grounds for hope.
Part of me is tempted to go through this process on my own first, but I think I may have greater luck in cutting through the bullsh*t quotient if I hook up with Gary Visio or Larry Slade *now.* This is not the time to be unnecessarily cheap.
Anyway, you know me by now: I always feel better when I'm doing something *concrete* to slay the insurance dragons, and I'm even looking on the