Moving Forward:
Our seminars are designed to be a stepping stone towards eventual insurance approval, surgical consultation, and the ultimate goal of surgery. All persons who attend one of the informational seminars will receive a white folder filled with written materials including the paperwork needed to begin the insurance approval process with our program. We include specific instructions on how to fill out the paperwork as well as information about gathering of medical records that your insurance company will require for prior authorization. See Insurance and Financing for more on checking your benefits and plan exclusions.
The Insurance Approval Process
Most insurance companies that provide weight loss surgery benefits to their subscribers require that the surgery go through a “predetermination” process. This means that the insurance company has created a set of criteria that the patient desiring surgery must meet before they will offer “prior approval.” Prior approval, per insurance policy, is not a guarantee of benefits. Please refer to your plan document for details. The predetermination process usually requires that the patient meet some physical standards, and some patients are required to undergo psychological and physical testing.
A “typical” set of criteria would include:
- A BMI > 40, or 35 to 39 with serious co-morbidities,
- 12-24 month diet history,
- Documentation of health history and co-morbidities,
- A psychological evaluation,
- A nutritional consultation with a registered dietician,
- 6 months of medically supervised dieting in the past 12 months, and
- Labwork to rule out thyroid dysfunction or metabolic imbalance.
Please remember, this is only an example.
Each insurance company has different criteria that a patient must meet in order to be authorized for surgery, and even different plans within a company can vary in their requirements. At the Bariatric of Kansas City, we work closely with you to gather your records and screen them to see if you have already met some of the required criteria. Then we will help you arrange the testing and consultations needed to fulfill these requirements as quickly as possible. Once all of the information is gathered, we’ll write your letter of medical necessity and submit it along with your other documentation for predetermination.
Frequently Asked Questions:
- Should my primary doctor write my letter of medical necessity?
No, as your surgeon, that is our role. Even though your primary doctor is trying to be helpful, the insurance company expects your surgeon to send in all your information. However, if your primary or specialist physicians wants to write a letter of support that can be very helpful. Mostly what we need from your primary doctor is medical documentation of your health status that past couple of years, and what efforts you have made to lose weight under his/her guidance. If you haven't seen your primary doctor in the past 6 to 12 months, please have him/her do a thorough physical exam on you, and document carefully in your record all of your health issues.
- How long does insurance approval take?
Once your letter of medical necessity is submitted, it can take as little as a few days to as long as 6 to 8 weeks, or even longer, depending on the insurance company. That’s why it’s important that we send all the information in correctly the first time so delays are avoided.
- How can I help with the insurance approval process?
Please make sure that your doctor(s) forward your medical records to our office as soon as possible. Instructions for having records sent to our office are included in the folders distributed at the informational seminars. Once you know your predetermination request has been submitted, contact your insurance company weekly to check on its status. Make sure your insurance company actually received the request and remind them that you’re anxious to be approved.
- How Long Does It Take to Have Surgery Once I've Attended a Seminar?
This is probably the most frequently asked question that we get. We certainly under-
stand that patients are anxious to move forward to surgery after years and years of
struggling with their weight. You also want to stop the potential and/or advancement of
dangerous co-morbid health conditions. We want to help you move toward your weight
loss goals as well.
However, there are numerous steps involved in readying a patient for surgery, including
reviewing past medical records, consulting with other medical specialists, meeting insur-
ance criteria for approval, and making sure the patient is ready for surgery both
medically and psychologically. This process can take anywhere from 2 to 6 months from
the time the patient attends a seminar to the time of their surgery, depending on all of
these variables. Some patients even have to work for a year or more to meet their
insurance company's criteria. Your insurance company would have you believe that the
process of prior approval is very simple, but this isn't so. Our program will help you
every step of the way, and we appreciates the cooperation and patience of each
patient.
We believe that the process of readying a patient for surgery of this nature should not be
rushed. Our goal is to expedite each patient towards surgery on an individual basis with-
out compromising either their safety or ability to have a successful outcome. Obtaining
weight loss surgery is not a race; it should be a process where you learn to make major
lifestyle changes so adjustments with your new tool after surgery can lead you to a
successful weight loss outcome. For most patients, this is their one and only chance to
finally reach their weight loss goals. We want to help you do it right.
**For Self Pay Patients: If you’re interested in moving forward with surgery after attendance at the Informational Seminar, because their is no insurance company involved, you will naturally move faster through the process. Please review your seminar information carefully for specifics.
Consultation with Your Surgeon
Once a patient has submitted their medical records to us and chosen which procedure they want, we will begin their consultations. You start out seeing the psychologist and dietician, and any other testing and clearances as required by your insurance company.
Note: Insurance approval or an initial consultation with the surgeon does not guarantee that a patient is a candidate for our weight loss surgery program. Candidacy is being evaluated throughout the entire preoperative phase by all disciplines involved in your care. The bariatric program and our surgeons reserve the right to dismiss a patient from the program without cause at any time.
Over the past years we have developed the following general sequence for our weight loss surgery patients:
- Patient attends informational seminar
- Paperwork is completed by patient and submitted to our office along with medical records as required for insurance predetermination
- If appropriate, patient will be referred to clinical psychologist and dietician for consultation.
- If patient’s insurance company requires specific criteria be met, our office will contact the patient and arrange other consultations, testing, or discuss other details.
- Once the patient meets the insurance criteria, our office submits letter of medical necessity to insurance company along with other required information.*
- Patient receives either prior-authorization for surgery* or is notified of denial
- Once approved by psychologist and insurance, patient makes office consultation appointment with surgeon.
- At office consultation with your surgeon, your surgeon will review your records, answer your questions and discuss how best you should prepare yourself for surgery. A surgery date will be arranged if your surgeon feels it is appropriate.
- Lap Band and Gastric Sleeve patients are only seen once in our office before surgery; Gastric Bypass patients are seen twice.
- Special note to self-pay patients: payment is required by our office and by the health care facilities one week before the date of surgery.
*Does not pertain to self-pay patients
Meeting With Your Surgeon At your first surgical consultation, you will be meeting with your surgeon to discuss in more detail the procedure you have chosen and how it will affect you and your lifestyle. Your specific health issues will be reviewed, and the risks and benefits of the surgery will be addressed as well. You will have the opportunity to ask many questions, and you will be given educational information, and in most cases, a surgical date will be chosen. You will have the opportunity to meet the office staff as well. We encourage you to bring family members or support persons with you to this initial consultation. You will eventually be asked to sign a consent indicating that you understand the nature of the surgery itself, along with the risks and benefits.
Patients undergoing the Laparoscopic Roux-en-Y gastric bypass are required to attend a second office consultation with their surgeon approximately one week before their surgery, for final review of all lab testing and consultation reports. At that second consultation you’ll be taking a simple pre-operative test which helps us rate your level of comprehension regarding the nature of the surgery and your readiness for the procedure itself.
Multidisciplinary Consultations
Our program’s philosophy is based on caring for the whole patient, physically and mentally, to enhance their ability to succeed with the weight loss surgery that they have chosen. That is why we do everything we can to make sure that each patient is prepared as fully as possible for their upcoming surgery. This involves sending our patients to outside consultations with experts in the fields of cardiology, pulmonology, and clinical psychology, as well as referring them to nutritional experts, exercise therapists, and an experienced bariatric hospital coordinator. We all work closely with the patients’ own primary care physicians or internists, as well as other specialists such as endocrinologists, nephrologist, and orthopedists, to help ensure that they are medically stable and good candidates for surgery. This philosophy aligns with ASMBS Center of Excellence Standards. |
