Friday, March 26, 2010

You Want Surgery, So Now What?

So now that you have chosen a surgery type, now what?

Now you need to research to see if your insurance covers WLS. Most people who have medical insurance do not have WLS benefits. If you have WLS benefits, count your lucky stars!

WLS benefits are covered under group policies only. Private policies do not cover WLS and the reason is that all the people (majority) who do not have WLS benefits would be buying private policies in order to have insurance companies pay for their surgery. As soon as their surgery was complete they would drop the policy. No insurance company could afford that for long. Thus, private policies do not cover WLS.

Group policies do cover WLS IF the WLS premium is paid. Let's say you work for a large company, your chances for having WLS benefits are good. Typically the larger companies will pay the additional premium for WLS. If you work for a smaller company it is unlikely you have the right benefits. Smaller companies cannot typically afford the expensive premiums. They cannot just cover one or two employees, it is all or none. Either they have to cover all employees or no employees.

Call your insurance company, ask if you have WLS benefits. Regardless if they say you do or you do not verify this with your own eyes. When you call your insurance company you are talking to a first level employee. They are not typically experts in insurance. Whether or not they claim you have benefits ask them to email you a link to your on line policy showing where WLS is included or excluded. Do not take their word for it.

If you do have WLS benefits ask them what you need to do to qualify for surgery. Most companies require part or all of the following:

A BMI of 35 or greater and very specific comorbidities such as high blood pressure where you need medications to control your disease. Borderline hypertension that is controlled by diet and exercise does not count. And/or, diabetes and no, prediabetes does not count. You must be a full blown diabetic on medications to control your blood sugar. Things like a family history of obesity, high blood pressure, diabetes, these do NOT count. Your insurance company does not care if your mother is diabetic or not, they want to know if YOU are a full blown diabetic.

Issues such as joint damage, back pain, headaches, PCOS, asthma, ... none of these issues matter. Well, they do to you but they do not matter to your insurance company in the least when it comes to qualifying for WLS.

If you do not have medical comorbidities such as the above you must have a BMI of 40 or greater.

Some insurance companies require you to prove through various types of medical records that you have had a BMI of 40 or greater for the last five years.

Some insurance companies require you to do a 3-6 month medically supervised diet. This means (usually) that you have to go to your nutritionist or physician every month for 3-6 months to be weighed and measured. Then your health care professional must document that they weighed and measured you and discussed with you diet and exercise. If you miss as much as one appointment your insurance company has the right to make you start over the entire medically supervised diet.

Many insurance companies require that you go to a nutritionist for an evaluation of your diet.

Many insurance companies require that you go to a bariatric surgeon to evaluate your weight.

Many insurance companies require that you go to a psychologist for a psych evaluation.

Many insurance companies require that have a sleep study done to see if you have sleep apnea.

Let's be honest here, they do not make this an easy process.

What if you do not have WLS benefits on your insurance? Well, welcome to the world of self pay. I'm not being snitty, I've self paid twice so I fully understand. Once for a Lap Band and again for a revision from band to sleeve. If you are in this position I can empathize with you. Please note, there are no organizations that will give you money for WLS. No doctors will do your surgery for free. They are asked on a daily basis and they would go out of business if they did free surgery, the costs associated with WLS are great in number. The cost of a Lap Band is $4,000 and that is just for the band. That does not include OR time, the anesthesiologist, medications, anesthesia, nursing, or all the other costs associated with surgery.

One of the many issues I have learned over the last four years is that if someone wants surgery badly enough, they will find a way to get it. Some save for years, some take from their childrens college funds. Some refinance their homes, some sell off personal items, some get 2nd and 3rd jobs to pay for surgery. People that want it bad enough find a way. It's a cold and harsh reality, yet true.

The next step is to find a doctor. Now, I realize this sounds odd. Most would have their surgeon help them pick a surgery type. That's fine as long as you go to a surgeon that does all the major procedure types. For example, let's say you want Gastric Bypass and you go to a surgeon that is a band mill, meaning they only do Adjustable Gastric Bands. They sell a product, their product is a Gastric Band. If you go there asking about a procedure they do not know how to do they are going to tell you the evils of all surgery types they do not do. Let's face reality here, doctors are in business to make money just like the rest of us. We all go to work to earn a living. Asking a band mill surgeon about Gastric Bypass is like asking a Toyota dealer to tell you all the best aspects of buying a Honda. They are going to push what they sell. Thing is... *you* are the person that has to live with your surgery type for the rest of your life. It is you that has to decide just what you can live with and what you cannot live with.

So either decide on a surgery type and then choose a surgeon that does that surgery or go to a surgeon that has no vested interest in which surgery you choose, you will get a much more balanced answer and more balanced suggestions to consider.

Please see "Researching Mexican Lap Band Doctors" on how to research your doctor, it will work for both US and MX surgeons. Please see "Researching Mexican Sleeve Surgeons" on how to research your doctor, it will work for both US surgeons and MX surgeons for sleeves and bypass. For DS the doctors are extremely limited and you should check on the website for suggested surgeons.

If you have WLS benefits on your insurance get a list of all the doctors they contract with and start going to seminars. Remember, go to a surgeon that does the surgery type YOU want. YOU have to live with this surgery type for the rest of your life, don't let a surgeon talk you into the surgery type he performs instead of the surgery type you want. I promise you, you will regret it if you don't.

If you do not have WLS benefits on your insurance plan, or if you do not have insurance at all then you can go to any doctor you wish. Remember, medical tourism is a growing industry. Surgery is MUCH cheaper and equally as good (with the right research) outside of the US. I did it, lots of people do it. I went to Mexico for my band as well as for my sleeve.

Go to lots of seminars, meet the doctors (if in the US), get a feel for them. See which doctor you feel comfortable with. In some ways the most important issue is surgical skill but you know, unless you get a sleeve you'll need follow up care for the rest of your life. You really need to go to someone you like and trust as well. If you hate your surgeon you are less likely to go for follow up care and that will affect your weight loss.

There is such a thing as a Center Of Excellence or a COE. You will see this often on various WLS message boards. Please do not assume this makes the surgeon good. Some of the worst surgeons are a COE, it merely means the hospital they work out of meets certain requirements. It means absolutely NOTHING about surgical skill.

Choose a surgeon with lots of experience. There is a learning curve to every surgical procedure including removing toenails! Don't be the guinea pig, be the patient that goes to a good, experienced surgeon with great stats, lots of skills, and oozes compassion and understanding of obesity.

Now it is time to choose a surgery type and get your life back!

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