It's the Kaiser plastic surgery dept that fights the existence of Lipedema. The first time I did an appeal with Kaiser for Lipedema surgeries I was approved (that was in Nov).
It is Kaiser’s policy that if they approve an appeal, for an out of network dr/procedure, the Chief of the dept who would normally do it (in our case the plastic surgery dept), is given the task to write the Outside Referral. It's the Chief of Plastic Surgery who sees any patient who has/thinks they have lipedema. The Chief of Staff of plastic surgery, vehemently insist lipedema is a made up internet disease.... You can't proceed with surgery until you get the outside referral.
When Kaiser's appeal reviewers, approved my surgeries, the rules in my EOC (Evidence of Coverage) says they have 7 days to write the Outside Referral. The Chief of Plastic Surgery refused to write the outside referral. The Appeals Dept employee said they couldn't force the dr when he would write it.
In March, after 118 days, the Kaiser Chief of Plastic Surgery, convinced the Appeals Dept to overturn my approval and issue me a denial.
The real problem is that the Chief of any Kaiser dept has a, Conflict of Interest, and should NOT be involved in writing the Outside Referral.
Each year, the Chiefs of the Depts are given a budget. (They think of it as their budget, but it is the budget for patient care)... In the event the dept is unable to treat a medically necessary condition, if the patient is treated out of network, the money for the patient's treatment comes out of the Chief's dept budget. At the end of each year the dept chiefs get a bonus based on how much money they have left in their budget.
Our multiple surgeries cost alot. My 5 surgeries were $125k. If they had to pay for all the lipedema women who are Kaiser patients, that Chief of Plastic Surgery is thinking, "There goes the boat." ... Kaiser’s method incentivises Chief's to deny patient care, otherwise they personally make less money.
I did go forward with an Outside Appeal, which I won. Kaiser had No Choice, they legally Had To Pay.
Hi Liz, Read your Kaiser Evidence of Coverage (EOC). It will have an Appeals section, probably towards the back. Follow what it says for the steps to take. Miss NO dates of when things are Due Buy or your appeal will end immediately. (I have Medicare Advantage so my appeal process is somewhat different than standard Kaiser)
Expect denials, but keep appealing, your chances are best when you get to the outside review, then Kaiser has no say, and if you win, Kaiser has no choice, they have to pay.
During the process keep making your documents better and stronger so that when you go to the outside review, your case will be it's strongest.
Send ALL of your photos to Kaiser, because Kaiser will have to turn over to the outside reviewer everything you have given them. Kaiser is allowed to send them a PDF so your photos will look perfect. We patients are only allowed to send a paper document which the outside reviewer only scans in black and white plus it look like they fax it so no detail can be seen by the outside reviewer.
If you have anymore questions as Michelle to give you my email address.
Thank you so much, Terry for providing such detailed information. I really appreciate it. It's been a bit frustrating with the Kaiser physicians, and I have just started the process. They have not/will not refer me to a specialist, running all sorts of useless labs instead.
Liz, Kaiser can't refer you to a specialist, they don't have any on lipedema. What are they trying to prove with the tests? Probably getting evidence that they will try to use against you saying you don't have lipedema. Have they offered you a, lymphoscintigraphy test. They will probably deny you that because that can posssibly give you proof to use against them.
Pam, this is an excellent account of Kaiser's tactics to not pay for lipedema surgery. Kickbacks like this should be criminal. I'm never astounded by the ways insurance is able to deny treatment to patients.
Yes, when I went to cleveland clinic the doc told me easier and less expensive to go to Germany. said Germany is top in the world for Lipedema. I wasn't up to going to Germany though.
Many women go to either Germany or Spain for surgery. They're more advanced with liposuction surgery there than in the States. And the cost is much more affordable.
It's the Kaiser plastic surgery dept that fights the existence of Lipedema. The first time I did an appeal with Kaiser for Lipedema surgeries I was approved (that was in Nov).
It is Kaiser’s policy that if they approve an appeal, for an out of network dr/procedure, the Chief of the dept who would normally do it (in our case the plastic surgery dept), is given the task to write the Outside Referral. It's the Chief of Plastic Surgery who sees any patient who has/thinks they have lipedema. The Chief of Staff of plastic surgery, vehemently insist lipedema is a made up internet disease.... You can't proceed with surgery until you get the outside referral.
When Kaiser's appeal reviewers, approved my surgeries, the rules in my EOC (Evidence of Coverage) says they have 7 days to write the Outside Referral. The Chief of Plastic Surgery refused to write the outside referral. The Appeals Dept employee said they couldn't force the dr when he would write it.
In March, after 118 days, the Kaiser Chief of Plastic Surgery, convinced the Appeals Dept to overturn my approval and issue me a denial.
The real problem is that the Chief of any Kaiser dept has a, Conflict of Interest, and should NOT be involved in writing the Outside Referral.
Each year, the Chiefs of the Depts are given a budget. (They think of it as their budget, but it is the budget for patient care)... In the event the dept is unable to treat a medically necessary condition, if the patient is treated out of network, the money for the patient's treatment comes out of the Chief's dept budget. At the end of each year the dept chiefs get a bonus based on how much money they have left in their budget.
Our multiple surgeries cost alot. My 5 surgeries were $125k. If they had to pay for all the lipedema women who are Kaiser patients, that Chief of Plastic Surgery is thinking, "There goes the boat." ... Kaiser’s method incentivises Chief's to deny patient care, otherwise they personally make less money.
I did go forward with an Outside Appeal, which I won. Kaiser had No Choice, they legally Had To Pay.
Hi Pam. Thanks for the insight. How did you go forward with an outside appeal for Kaiser to pay? Thanks, Liz
Hi Liz, Read your Kaiser Evidence of Coverage (EOC). It will have an Appeals section, probably towards the back. Follow what it says for the steps to take. Miss NO dates of when things are Due Buy or your appeal will end immediately. (I have Medicare Advantage so my appeal process is somewhat different than standard Kaiser)
Expect denials, but keep appealing, your chances are best when you get to the outside review, then Kaiser has no say, and if you win, Kaiser has no choice, they have to pay.
During the process keep making your documents better and stronger so that when you go to the outside review, your case will be it's strongest.
Send ALL of your photos to Kaiser, because Kaiser will have to turn over to the outside reviewer everything you have given them. Kaiser is allowed to send them a PDF so your photos will look perfect. We patients are only allowed to send a paper document which the outside reviewer only scans in black and white plus it look like they fax it so no detail can be seen by the outside reviewer.
If you have anymore questions as Michelle to give you my email address.
Thank you so much, Terry for providing such detailed information. I really appreciate it. It's been a bit frustrating with the Kaiser physicians, and I have just started the process. They have not/will not refer me to a specialist, running all sorts of useless labs instead.
Liz, Kaiser can't refer you to a specialist, they don't have any on lipedema. What are they trying to prove with the tests? Probably getting evidence that they will try to use against you saying you don't have lipedema. Have they offered you a, lymphoscintigraphy test. They will probably deny you that because that can posssibly give you proof to use against them.
Which Kaiser do you go too? What stage are you?
Pam, this is an excellent account of Kaiser's tactics to not pay for lipedema surgery. Kickbacks like this should be criminal. I'm never astounded by the ways insurance is able to deny treatment to patients.
Yes, when I went to cleveland clinic the doc told me easier and less expensive to go to Germany. said Germany is top in the world for Lipedema. I wasn't up to going to Germany though.
Many women go to either Germany or Spain for surgery. They're more advanced with liposuction surgery there than in the States. And the cost is much more affordable.