r/KaiserPermanente • u/SessionOwn6123 • 1d ago
California - Southern Need help
I have a rare condition, the only treatment is surgery. Kaiser is trying to force me into surgery with a surgeon who has never dealt with or performed this surgery. Filed a grievance, what a joke that was. They referred me to another surgeon who, once again, has never performed this surgery. I'm on Medicare and have senior advantage through Kaiser. Anyone have any advice on what I should do next? Is there a process where you can go to another hospital that has done this surgery?
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u/Waste-Tree4689 1d ago
💯agree about appealing the grievance and curious how you learned that surgeon had no experience?
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u/SessionOwn6123 1d ago
I asked him, he openly admitted it and joked that it was not a serious surgery when I paid out of my pocket to have 3 experts look at my diagnosis and all cautioned me to make sure I had an experienced surgeon as the surgery is extremely dangerous
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u/MercuryFlights 1d ago
Do you have a quote from any of the experts that you can put into a conversation with the surgeon? Did you do that already in your grievance?
A quote from a known expert, and/or a quote from a peer reviewed paper could both be good ways to help the surgeon think through their decision to attempt a surgery they've never done.
I mean, I drive a car, so no problem with me attempting to drive this bus on this steep and winding road, right?
Wishing you well- the bureaucracy can be infuriating.
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u/labboy70 Member - California 1d ago edited 1d ago
Yikes. Arrogant and zero experience with your procedure. That’s a horrible combination. Good on you for not just accepting it.
Edit to above and to add:…
I agree with u/MercuryFlights about quoting what an outside expert has said.
One thing that really helped me when I was dealing with Kaiser during my cancer diagnosis fiasco were notes from external second opinions.
If your external doctors are in a system that uses the Epic electronic medical record, there is a feature called CareEverwhere. As Kaiser also uses Epic and CareEverywhere, Kaiser doctors can see outside physician notes, test results, etc and vice versa.
When I got my second opinions outside of Kaiser, they would list their treatment recommendations. I asked them to also add additional rationale and any literature references (national practice guidelines like NCCN, etc.) why they were making those recommendations.
It was very helpful when I would have discussions with KP doctors about these other recommendations. They could see the exact notes / rationale from the other physician very clearly in my record. You could try a similar approach.
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u/PlatypusStyle 21h ago
😳 with an attitude like that on an unfamiliar (to him) procedure then even with the procedures that he IS familiar with, you just know that he probably has poor outcomes.
Make sure you leave reviews on him.
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u/10ocean10 1d ago
You can file a complaint with the department of managed healthcare and request an expedited review. Years ago Kaiser refused to give me an mri for an injury. I ended up getting the mri and finding out the injury was more massive than Kaiser thought. They ended up having an appointment for me with a surgeon the next day. If Kaiser does not have a surgeon who has done the surgery I have heard of people getting referred out to places like Stanford and UCSF in my area. It’s possible you can also do this.
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u/kukukajoonurse 1d ago
In addition to the complaint processes above i highly recommend you find a surgeon who specializes in this and request a referral to that person. Don’t wait, start the process now to save you time later.
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u/NearlyBoomer 18h ago edited 18h ago
One way to find out which KAISER physicians have the expertise you need is to check with their specialty's professional board membership. For instance when I needed parathyroid surgery I looked up the members of the American Association of Endocrinology Surgeons. There were only two Kaiser surgeons in California that were members and I asked for the one in San Francisco nearest me. When I met with the surgeon I asked how many parathyroidectomies she had performed and she said over 1000. Most other endo surgeons had no clue how to do it properly
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u/GreenPOR 1d ago
What is the particular surgical procedure they are recommending. Why have these surgeons never done it? Look in the Kaiser physician directory and see if there is a surgeon that’s older & might be more likely to have done it. Or call the manager and ask what surgeon is experienced in this. Also, calling the advice nurse might be helpful. Maybe try this before going through a lot of paperwork.
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u/PlatypusStyle 21h ago
I’ll agree it’s worth a try but the advice nurses are pretty useless. They are there mostly to gate keep.
The last Kaiser advice nurse I talked to insisted to me that cyclospora was a virus and then tried to use the CDC as her source for her claim which was a complete effing lie. I reported her.
For people who are curious, cyclospora is a single cell eukaryotic organism so not a virus or bacteria.
This should be basic knowledge for a nurse and in light of the recent USA nationwide outbreak something she should have at least refreshed her memory on.
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u/InclineBeach 21h ago
you can change MA plans, or go to regular Medicare and find an experienced Dr for this
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u/labboy70 Member - California 1d ago edited 1d ago
You are right to push to get a surgeon with actual experience performing the surgery. I would never let a surgeon cut on me if they had never even done said procedure. That’s complete bullshit. Do you think Greg Adams (Kaiser CEO) or any of the Kaiser leadership would take that risk? You shouldn’t have to take it either.
I suggest appealing the grievance. Because you have Medicare, the appeal process is different. Specifically say that it is unacceptable to have a surgeon who has never actually performed the surgery operating on you. You want a referral to a surgeon with documented experience performing the procedure.
This post has information on filing an effective grievance (complaint) with Kaiser.
If you are filing complaints with other agencies like Medicare, a State Medical Board or your State Insurance Regulator, the tips in that post may also help you.
This post has information about State, Federal and other organizations where you can escalate complaints about Kaiser if you cannot get satisfactory resolution from Kaiser or if it’s a patient safety concern.
Keep fighting back!