Some of you might be interested in weight loss surgery and all the ins-and-outs in preparation for it. I made the decision to have surgery after watching several family members struggle with Type 2 Diabetes mellitus. At least eight family members have been negatively affected by this disease. All but three of them are dead due to complications from Diabetes. A few of them had to have their fingers and toes amputated. One of my cousins went blind. I was diagnosed with hypoglycemia about 12 years ago and was told that I too would become insulin-dependent as I get older. So, in theory, I’m staring diabetes in the face and we are at an impasse. It’s only a matter of time before it catches up to me and slowly kills me. Its torture devices are needles, dependence on temperature-controlled medications, and reactive hypoglycemia followed by heart disease, diabetic neuropathy, dialysis machines, amputations, loss of vision, disability and finally death either due to sepsis or some kind of organ breakdown. Enough about my reasons, let’s get down to the business, pardon the pun.
If you are one of the fortunate people who have private health insurance then God bless you. However, it is not an easy road trying to get your insurance carrier to approve weight loss surgery. Insurance companies are in business to make money and if you suddenly become healthy they can’t make money off of you like they can with someone who has a chronic illness. Trust me when I say this: insurance companies are in business to make money, (I am a former Insurance Sales Agent). Each person’s health coverage is different depending upon the contract between the insurance company and the employer that is providing your coverage. Obviously your employer is paying a portion of your benefits and they can choose what benefits that they are willing to pay for. Some do not offer coverage for weight loss surgery, (also called bariatric surgery). You have to check with your insurance company. Locate your insurance card, turn it over and you should find some phone numbers listed. If you call the insurance company you will need to call the phone number listed for members, (that’s you). Your card may also have a phone number for providers. That number is for your physician or nurse to call. My advice to you is to call your insurance company and find out if weight loss surgery is a covered benefit. Most insurance companies require that the surgery is “medically necessary” before they will pay for surgery. If you can get the representative for your insurance company to give you any information about the payment structure you need to ask the following questions:
1) What is my individual deductible?
2) What percentage of the charges will I have to pay after meeting my deductible?
3) How much should I expect to pay for weight loss surgery?
4) What is my maximum annual out-of-pocket expense?
5) What criteria must be met for me to meet the minimum guidelines for weight loss surgery?
6) Does my covered benefit require any weight management prior to surgery?
7) Can you give me the number of a provider who is “in-network?”
8) How much will my plan pay for a provider that is “out-of-network?”
If there are providers that are “in-network” close to where you live, that’s wonderful news! However, you are not ready to call them yet. Ideally you should research the surgeons before you settle on one to perform your surgery. You can Google them or ask around and find out as much information as possible before settling on one provider, (doctor). Oh, by the way, get used to calling your doctors and/or nurses, providers. They are providers in the sense that they are providing a service for you in exchange for money.
Now you are ready to contact your primary Physician and make an appointment with them to discuss your choice to have weight loss surgery. If you don’t have a primary Physician, you need to get established with one as soon as possible. More than likely your insurance company will require that you or your healthcare provider submit your health records to them prior to surgery. This is usually one the requirements to satisfy your insurance company and oftentimes your healthcare provider will request them, too. After you meet with your physician and he or she agrees to support your decision AND they have determined that you meet the minimum guidelines for weight loss surgery then you are ready to contact the surgeon’s office. Your primary physician’ office should send a referral letter or fax to the surgeon’s office. Once they receive the information and determine that you would be a good candidate for surgery, the surgeon’s office will usually call you to set up an appointment. Again, check with your insurance company and your physician to find out. My insurance company requires the following criteria for surgery:
1) BMI, (Body Mass Index) of 40 or greater consistent for the last five years. If you don’t know what your BMI is contact your physician.
2) BMI of 35 or greater with any of the medically treated co-morbidities,( one or more additional disorders or diseases co-occuring with a primary disease) listed:
- Sleep Apnea
- Failure of other measures to lose weight, such as medications, weight loss programs, and/or dietary changes.
3) You must be healthy enough for surgery because there are risks, including death.
4) Ability to understand lifestyle changes and motivation to comply with program guidelines.
5) Absence of medical/psychological contraindications. (Basically you have to be cleared by a Psychologist prior to surgery to make sure that you are not suffering from an acute, uncontrolled mental health condition).
Your bariatric surgeon may also require you to meet certain criteria. Many require you to quit smoking prior to surgery and you will most likely be tested for nicotine in your system. You must have a referral from your primary provider’s office sent to the bariatric surgeon’s office. Many require that you attend at least one education class and a minimum of one support group meeting prior to surgery. My provider’s office required that I have a “normal” thyroid blood panel. Mine also required that I have a complete physical with my primary physician or gynecologist within the last year. If you have any heart, lung, stomach, intestinal problems expect for those areas to be tested prior to surgery as well. My insurance company required that I went through 6 months’ of medically supervised weight management prior to surgery.
Now, you could do all of the following to a perfect tee and yet the insurance company has the final say and approval for surgery. Once my surgeon’s office submits all of my medical records to the insurance company, (that’s usually the last step right before surgery), then I may have to wait up to 15 days for approval from my insurance company. Once I get the approval then I will be put on the surgeon’s surgery schedule and be required to go on a low-carb diet for about 10 days to shrink my liver, (most people who are obese have fatty livers). Some surgeons require that you go on a liquid diet for 10 to 14 days prior to surgery. The day before surgery I will be required to consume a complete liquid diet. I can drink a protein shake for breakfast and lunch and skip dinner the day before my surgery.
As you may interpret from the above, I have one last step to complete before all my records are submitted to my insurance company. I have already seen a Psychologist, but I have to take a Psychiatric test consisting of 344 questions. It has to be scored by the Psychologist. He or she has to write a report, several pages long, summarizing their evaluation of me and submit that to my insurance company as well.
As you can see, this is not an easy process. I’ve gone through this process twice due to some insurance issues. I have to travel to another state 2 hours away from where I live in order for my insurance company to pay 100% for the covered charges. If you make it through all the above criteria, expect a bill from every provider you encounter. You will most likely receive a bill from the hospital, the surgeon, the anesthesiologist and a radiologist. You may also incur other bills depending upon the severity of your health condition(s). Any co-pays, co-insurance and/or deductibles have to be paid prior to surgery. If you have any questions, always contact your healthcare providers and/or insurance company.
If you decide to move forward with the weight loss surgery process – I wish you the best of luck!
Until next time….
Peace & Love – may you find it, embrace it and spread it around…….