Desperate!!! Referral Approval Help - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

Jtcox88 · 02-11-2008, 11:44 AM

I had GBP 2 years ago and now I need to have my gallbladder removed. My insurance is refusing to approve the referral to my GBS surgeon (who is already a contracted surgeon) because he is not "capitated" with my medical group (HMO). But here is the thing that is infuriating me... All of the surgeons that are "capitated" will refuse to operate on me because of the GBS. Great!!! That is EXACTLY what I want!!! The only thing is that I have to go see the general surgeon first, THEN they will refer me to my GBS surgeon. The first available appointment isn't until 4/7/08!!!!!! WTF!!! I can't wait that long. I am serious pain here!

Does anyone have any ideas how in the heck I can get around the HMO system?

katzz87 · 02-11-2008, 11:51 AM

No advice to give you...but I'm so sorry you are in so much pain! I've heard that gall-bladder pain is the worst!!!

I didn't realize that regular surgeons wouldn't do surgery on GB patients. This true??? Yikes, if so!

mikeswife4 · 02-11-2008, 02:53 PM

hope that I can help..I work for an hmo (yes I know they suck!) and I also had my gallbladder removed about 10 yrs ago due to hrt attack like symptoms. After 3 er visits where they told me that I had gerd. One smart doctor referred me to a general surgeon. the ct scan showed stones the size of lemons...I had surgery one wk later. as the processor of many hmo authorizations I can tell you that you should be able to go the er next take you are in pain and they should take you to the or and remove your gallbladder immediately....HMO EE in San Diego, CA

Native2u · 02-11-2008, 03:13 PM

I was going to say the same thing....

Go to the ER next time you are in really bad pain, they have to help you there. I haven't had lap band surgery yet, but, I have had my gallbladder out and that was years ago.

FYI: I refused to go to the doctor or ER cause I thought I was just having really bad indigestion. One night, several days later, I thought I was dieing. I went to the ER and they said that I had to have it out...and now! That was on a Sunday evening. I was admitted into the Hospital and my gallbladder was removed on Wednesday morning. I was totally jaundice, the white part of my eyes were yellow. The stones that I saw were huge and they had ruptured and turned inside out. That was VERY painful!

Cinerbelle · 02-11-2008, 04:22 PM

I went to the ER when I had gallstones and they did not take me directly to the OR. I was in the ER for 9 hours and then I had to wait 4 weeks for surgery.

Jtcox88 · 02-11-2008, 10:26 PM

I have already contacted Dr. Suh's office. Once I get the referral approved, he will see me the same day & surgery within 1-2 days. He is so awesome & I can't even get to go see him. I think that my next move is to go to the ER at Inland Valley with "possible complications to GBS" & have a consult with Dr. Suh in the ER. At this point that is the only way I think.

SueRN · 02-13-2008, 04:59 AM

If you go to the ED for gallbladder pain, they won't take you right to the OR unless there is an urgent need for the surgery. Just having the gallstones is not enough. If you have elevated liver functions, or a stone stuck in the duct, or stuff like that. I went to the ED and was admitted, placed on IV fluids, clear liquid diet, and Iv Abx for about a week. Since my liver tests improved and their surgery schedule was full, they let me go home for a few days and came back to have the surgery. This was back in 1990. The asked me if I would left them perform the surgery laparscopically as they just got in the equipement and had only done the surgery on dogs. I was like no thanks...you're not going to practice on me and had the open. When I woke up after the surgery I hurt so bad that my very first thought was I should have done the lap! Gall bladder pain just plain sucks. Hope you can get seen soon. Sue

Alleusion · 02-13-2008, 08:12 AM

I had my first gallbladder attack in October 06 and didn't have it removed until Feb 07. Unless it's absolutely emergent, they won't remove it just by going to the ER. They will however attempt to control your pain if needed. I never developed stones though, just had duct issues where they weren't releasing the bile and getting irritated in the process.

What sucks about it.....I still have that problem. Removing the gallbladder doesn't remove the ducts that are still in your liver, so occasionally those get backed up like before. Do you know the kind of pain that can cause in a pregnant woman?

As for the insurance referral....going to the ER for your gallbladder and saying you think you're having complications from WLS, isn't necessarily a lie. WLS can cause gallbladder problems. If it helps getting into your doctor sooner, by all means use it.

ladytonya · 02-14-2008, 08:57 AM

I had my gallbladder out by a surgeon that doesn't do WLS. I was paranoid but all the research I did said that it didn't really matter because they couldn't do anything to your surgery site during the gb removal. My surgeon said he didn't even see but one small part of my stomach during the gb removal. Good luck! I hope you can get an answer soon!

Jtcox88 · 03-09-2008, 08:56 AM

Holy cow!!! I raised enough hell & my insurance approved me to ge see my surgeon! I am so friggin excited. I can't believe that I am saying this, but I am actually looking forward to another surgery (almost). I have been in isery for months now, & it will soon come to an end.

To all with insurance woes... be a huge pain the a$$ & you just may get your way! I had appealed the decision 3 times & I went all they way to the state HMO appeal board. I can't say which one was the actual turning point, but I was unrelenting.