1st Post-PreOp-Pacificare HELP! - ThinnerTimes

Veruca Sault · 08-26-2005, 09:35 PM

Hello my new found friends! I am hoping that some people locally in the San Diego/South Riverside areas can share some of their experiences with Pacificare HMO with me. Hopefully you can make it through my long winded post!

My situation has been beyond aggrivating, and at this time very stressful. I have cycled through 3 different insurance companies in the last three years and to be honest I am tired of putting myself out there for rejection.

Initially approve by Blue Cross/Blue shield in 2002 I was set for surgery when I found out that due to changes 1/02 I would have to pay $7K out of pocket for surgeons fees as BC/BS doesn't feel the surgeons fees are "reasonable" and will only pay the actual hospital cost.

Move on to United Healthcare with my new employer. Everything absolutely set to go for UHC but I wasn't eligible for FMLA and I had a very not understanding supervisor that made it impossible for me to get the time off. ( needed to keep that job) In order to compromise, I agreed with my employer that I would wait to take leave until March 2005.

As of 1/05 my company itself has chosen to exclude GBS from the UHC plan all together. I don't think it was a cock block (for lack of better terminology here) on a local level because they don't make the insurance decisions. Thats handled @ corporate level.

Now I have Pacificare. This is an HMO and the only HMO I have experience with is Kaiser. (In retro I shoulda stuck with kaiser as their 6 month diet hostory isn't at all so bad after I see the hell I am going through)

All of my tests were done thru Sharp, and initially I was going thru Dr. Mueller. he dropped me like a hot potato once he found out I no longer had UHC. Thats actually a blessing, as Dr. Callery and Dr. Potts seem so much more sensitive. When I left UHC I had to find a PCP that could still refer me to Mueller and thats how I ended up with "Sharp Community Medical Group" which was a nightmare to say the least. They wanted to charge me $650.00 out of pocket for "6 months of medically supervised diet" even though Pacificare insisted they would cover diet.

I stuck with this doctor, because Sharp was "Very Confident" that come September they would have the contract for pacificare. I stuck around in hopes that would happen because I had that rapport built up with Sharp.

Needless to say, I had a falling out with the doctor who chastised me for not being able to be weighed on his scale. FIRST OF ALL - A doctor touting himself as a "GBS referral specialist" should HAVE a scale to accomodate someone over 350lbs. I gave up on this doctor, he was so insensitive, and greedy too.

I now have Sharp Rees-Stealy medical group and haven't heard that they require any prerequesites like 6 month medically supervised diet. However, little surprises pop up around every corner, so I guess the best place to look is here.

Questions:

Any info regarding Sharp Rees-Stealy referrals, Issues, concerns or ANYTHING related to getting a referral outta these ppls!
any info regarding road blocks with pacificare HMO
Any information regaring Pacificare HMO vs PPO was one easier to get approval with over the other

*Thanks for Looking!

newbetterme · 08-26-2005, 10:11 PM

Hi I had PC HMO via Sharp Community. I had a really easy time getting through and approved. I to was referred to Dr. Mueller but Dr. Callery at that time held the contract for Sharp Community. I dont know if they required 6 months or not as i sent them 10 years of documented medical files.

But as far as road blocks i didnt experience any and since its an hmo and you are admitted into the hospital i didnt pay anything.

I think i have read on some post about some problems with Sharp Rees Steely. You might was to do a seach and see if there is anything in any of the posts.

Good Luck

Red Feather · 08-26-2005, 10:31 PM

I don't know who your dr. is. (Please don't post their name here) but I have PC HMO @ SRD. I'd be happy to share, IM me. Yes they did require a 6 mos plan - I just posted on the thread "starting out" - check that post - I speak a little about the process (for me) there! I'm here if i can help.

Veruca Sault · 08-26-2005, 10:53 PM

I Have thought long and hard, attended three seminars total from all major bariatric centers in San Diego. I have spent a total of 6yrs working out the kinks and thoughts as to WHY I want to do this.

Recently married, I want to have kids, and a family. The last time I had a period was December of 2004 and I stopped taking depo-provera in January of 2004. My husband and I want to have children and because of the risks involved in having children post 35 we want to do that within the next three years.

I have watched my weight, BMI and my ghetto booty grow in size even though I have reduced my food intake and increased my exercise. I think that this will be the right decision for me.

I have about 15yrs of diet history documented with past physicians, just nothing in the last three years except for the SCMG doctor who due to apayment dispute will only forward records for one of those visits he was charging me an insane amt of money for.

--TC

Ms.P · 08-26-2005, 11:24 PM

I have Pacific Care and came as a referral from Sharp. I had to complete the medically supervised portion but once that was over the approval seemed to go through quite painlessly.

Melanie
324/308/229/170

March 7, 2005- Dr. Callery

Veruca Sault · 08-26-2005, 11:32 PM

Which medical group specifically if I might ask Mel?

sUzYzPLaCe · 08-27-2005, 03:08 PM

OMG the story you just told about Pacific care HMO is exactly my story. Please feel free to instant message me and I will give you my telephone number to call, as this is just way too much information to try and type out here. I will tell you how to get around all the simple bullsh*t that they want out of you.. Suzy

wlcasper · 08-28-2005, 05:51 AM

My experience with Pacificare and Sharp Community Medical Group has been stellar. First of all the PCP is the kep. Dr. Kenneth Roth was mine and he got my surgery consult and approval right NOW! I also documented every diet I was on my entire life.

My wife who had her surgery in May had to go back and document her weight loss attempts before they would give her the OK. It was very simple, she filled out a log of her diets and sent it back to our PCP. The next day she had her approval.

Callery and Potts hold the contract for Bariatric surgery with Sharp Community Medical Group. I for one am glad they did and od. They are awesome.

If you have any questions, please feel free to send me a private e-mail.