Let me start by breaking the news that I finally learned this morning that after sitting on my file for more than five weeks, PacifiCare has
denied my pre-certification for WLS surgery with Dr. Juarez in Phoenix, on the grounds that Dr. Juarez and St. Luke's Medical Center are outside of my "Metro Tucson" service network. The doctor in the Medical Management Department who wrote the denial letter informed me that I need to be referred to a surgeon and hospital in Tucson, "including St. Joseph's", which is an unintentional joke that fails to amuse me.
Despite my request to Dr. Juarez and his staff that the re-authorization dictation specifically explain how and why I came to be a patient of Dr. Juarez and that there was no longer a covered Tucson surgeon available for my RNY, they appear to have submitted me merely as a first-time pre-certification patient, and PacifiCare apparantly denied me thinking that I'm an idiot who doesn't know that he's supposed to use doctors in his own city.
When my first surgeon abruptly stopped doing RNYs at St. Joseph's in July (he is the only Tucson surgeon who does WLS there) and cancelled my surgery less than two weeks before the scheduled date, I scrambled to find a new surgeon to start the process again. As an aside, many of you helped me through the shock and indecision of those days following the cancellation of my long-awaited RNY and I really thank you for that.
I called PacifiCare the next day and spoke to the first in a series of (apparently moronic - harsh but accurate) customer service agents, who told me that there would be no problem getting a prior authorization in the "Metro Phoenix" network if there was no covered WLS surgeon in the "Metro Tucson" network for me to use.
I eventually chose Dr. Juarez in Phoenix because of his reputation and experience and because I did not believe that there was an available alternative in Tucson who was covered by my insurance, with the possible exception of Dr. Monash, a new and MUCH less experienced associate of Dr. Schwartz. My former surgeon, Dr. Schwartz, is one of only three bariatric surgeons presently practicing in Tucson, although Dr. Monash and Dr. Lee (who have both just completed bariatric fellowships) are expected to start practicing RNY in town soon.
Apart from Dr. Schwartz, there are two respected, experienced local bariatric surgeons, Drs. Chiasson and Burpee, in partnership on the other side of town, whose program at Northwest Medical Center is in the process of earning a Center of Excellence designation. I have met a number of their patients, who are very pleased with their skill and their program.
Drs. Chiasson and Burpee were my first choice after the cancellation by Dr. Schwartz, based on what I'd heard about them and the fact that they were local, but I had understood from my original WLS referral process in January that PacifiCare didn't cover them. I looked again in my benefits manual, and was delighted to see their names under "Abdominal Surgeons - general", so I gave the office a call to see if they were covered for RNYs.
I spoke with Sonia, their office coordinator, and she told me that PacifiCare would cover Drs. Chiasson and Burpee for general abdominal surgery, but not RNY. She confirmed that PacifiCare patients used to have to go to Phoenix for their RNY surgeries until Dr. Schwartz came to town in 2006, and said that they'd probably have to start going back up to Phoenix since Dr. Schwartz had switched to only doing LapBands. So, I started the RNY ball rolling again with Dr. Juarez, and another moron from PacifiCare told my referring PCP that there would be no problem with that, because Dr. Juarez would not be considered "out-of-network" anyway, because he used to do all of the Tucson RNY surgeries....
After the cancellation, I stopped attending Dr. Schwartz's WLS support group (actually for a variety of reasons, not the cancellation itself) and started attending the two TUSWLS groups instead, which are run and attended primarily by Chiasson and Burpee patients, but also some Juarez and Schwartz patients as well. After I had already had a consult, seminar, and six-hour block of "ABC" classes at St. Luke's in Phoenix and started the re-approval process with Dr. Juarez, I met Dr. Burpee at one of the TUSWLS support group meetings at Northwest Medical Center.
When I introduced myself as a Juarez patient and mentioned my cancellation by Dr. Schwartz, Dr. Burpee said "Oh,
you're the one who called! After you called, we got to thinking that there was no reason for PacifiCare not to be covering us for RNYs as well as our other surgeries, so we contacted them and learned that they
will cover us now for RNYs. You
could have had the surgery with us after all..." "Great," I thought "
now you tell me!" As it turned out, Dr. Chiasson had happened to overhear Sonia talking to me on the phone that day, and that conversation got him to call PacifiCare and confirm RNY coverage, but since I hadn't given the office my name or number, they had no way to contact me to tell me the news...
Fast forward to today. After Dr. Juarez's office faxed me the denial letter, I called Emily, Dr. Schwartz's office coordinator, to get a letter from that office stating that Dr. Schwartz is no longer performing RNYs at St. Joseph's or anywhere else (apparently PacifiCare is not aware of this), so that I can include that letter with my appeal to PacifiCare if I decide to go that route.
I also tried to call the doctor in the Medical Management Department who wrote my denial letter to see whether I could explain the situation personally without a formal appeal - no dice - moron # 12 told me he doesn't take any calls or messages. Any appeal will have to be the formal, written kind. I won't bother with the option given to make an informal verbal appeal via the customer service agents (I'm not kidding - it's in my denial letter) given these facts and my now complete distrust of dealing with any PacifiCare customer service agents ever again...
I also called Sonia at Drs. Chiasson and Burpee's office and confirmed that yes, indeed, they are contracted with PacifiCare to do RNYs and that my call in July was the catalyst for that.
I signed up for one of their mandatory information seminars next week, in case I decide not to pursue an appeal to use Dr. Juarez as my surgeon and instead seek re-approval with one of them, and can schedule a consult with whichever one of them I decide I prefer. They are less experienced than Juarez, but were trained in part by him (or so people have told me) and are well out of their learning curve, and it would be great to be able to stay in town for surgery and aftercare. I will keep you all posted...
I am now leaving to go to the Eastside TUSWLS meeting and will give a shorter version of this terribly long post
, to hear what they have to say about this new development...
The Saga Continues (loooong post)
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