Step by Step Process in Getting Approved for Bariatric Surgery

  • REFERRAL-Your doctor must call in a referral for you to our office. We obtain demographic information on you, including contact information, mailing address, and insurance information. At this point, our office verifies your insurance benefits to determine if your contract covers bariatric surgery or not. If your contract does not contain bariatric benefits, you will be notified in your welcome packet. You are mailed a welcome packet, which will include a date that you are scheduled for the informational seminar, instructions for writing a personal letter and diet history, seminar fee information, directions to the office, and a list of upcoming monthly support group meetings.
  • INFORMATIONAL SEMINAR-Once your doctor’s office has contacted the office, you are scheduled to attend an informational seminar. At the seminar, you will pay your seminar fee (an out-of-pocket expense for patient), complete your paperwork, and turn in your personal letter. You will also need to bring your insurance card(s) and I.D. along with your regular office visit co-pay (Dr. Mora falls under the specialist category if your insurance policy differentiates between a primary care and a specialist). You will also view a short video on the specific bariatric surgery you are planning to have and take a short quiz on information covered in the video. At the conclusion of the seminar, you will proceed to the consult with Dr. Mora.
  • OFFICE CONSULT - You will meet with Dr. Mora on an individual basis. He will do an evaluation on you. At this point, he will determine what tests and clearances you will need to have in order to complete your workup for your bariatric surgery. Our office will order most of the tests and will offer some phone numbers for you to call physicians to schedule those tests that we cannot order for you.
  • CLEARANCES- Dr. Mora will order some or all of the clearances below.
  • Six-month or 3-month (depending on your insurance policy), physician-monitored, weight loss program (you actually weigh in 7 for the 6-month requirement and 4 times for the three month requirement)
  • Psychiatric Clearance-we will offer you several numbers for area psychiatrists/psychologists, or with office approval, you may contact one of your own choosing.
  • Nutritionist Clearance
  • Cardiology Clearance
  • Pulmonary Clearance
  • Sleep Evaluation Clearance
  • Attendance at three monthly support group meetings prior to surgery (mandatory)
  • EGD-performed by Dr. Mora
  • SUBMISSION OF INFORMATION TO INSURANCE COMPANY-There will be no information submitted to your insurance company until you have completed the entire workup. The information will be faxed to your insurance company. Most insurances request that all the clinical information be faxed to them, which is the reason your predetermination is faxed rather than sent online. It usually takes anywhere from 5-10 days to receive approval for the surgery. After we receive your letter of approval, we will contact you to schedule your surgery. If you are a self pay patient, after completion of your workup, Dr. Mora will review your information, and we will schedule your surgery.
  • PREOP DIET-Prior to your surgery, you will need to be on a pre-op diet 4-6 weeks. The length of time on the pre-op diet depends on your BMI. You will have received a copy of this pre-op diet at either the informational seminar or the office consult. This diet consists of a protein shake for breakfast, a protein shake for lunch, and a low carb meal for dinner. Alterations to this diet can be made as needed, by Dr. Mora. Just contact our office if needed. You will need to begin your pre-op diet after you weigh in for the fifth time. If you have completed your 6 months of weigh-in prior to being referred to our office, you will need to start your pre-op diet the day after you attend the informational seminar and have your office consult. If your BMI is over 60, Dr. Mora requests that you begin the pre-op diet immediately.
  • SCHEDULE SURGERY-Once you have been approved and we have scheduled a date for your surgery, we will order your surgery with the hospital and obtain a pre-op appointment for you two weeks prior to your surgery. At your pre-op visit, you will meet with hospital inpatient registration and they will inform you of any fees you will have to pay the day of your surgery. Self-pay patients and patients with %50/50 coverage will need to pay fees to Dr. Mora on this day at the office. You will meet with the surgery team that will be working with you the day of your surgery and one of the nurses will get some more vital information from you. You will also meet with the anesthesiologist. The surgery team will also instruct you as to what time you will need to arrive at the hospital the day of the surgery and instruct you as to what medications you will take that day, and what medications you will need to bring with you to the hospital for after your surgery.
  • FINAL WEIGH-IN – After your pre-op with the hospital, you will need to stop in to our office for a final weigh-in prior to surgery.

FORMAT FOR WEIGHT LOSS SURGERY

PERSONAL LETTER

IT IS MANDATORY YOU GO BY THIS OUTLINE TO WRITE YOUR LETTER! THIS LETTER IS BEING SENT TO YOUR INSURANCE COMPANY TO ASSIST WITH YOUR APPROVAL PROCESS, SO IT NEEDS TO BE VERY CLEAR AND CONCISE. HAVING A GOOD, DETAILED, THOROUGH LETTER IS THE FIRST STEP IN PROVIDING YOUR INSURANCE COMPANY WITH WHAT THEY NEED TO APPROVE YOU!

  • PLEASE DO NOT BE VAGUE WITH YOUR LETTER. YOUR LETTER NEEDS TO BE VERY DETAILED!
  • PLEASE TYPE YOUR LETTER. IT IS EASIER TO READ FOR YOUR INSURANCE COMPANY AND US! IF YOU DO NOT HAVE ACCESS TO A COMPUTER OR A TYPEWRITER, YOU MUST PRINT (NO CURSIVE)VERY LEGIBLY AND CLEARLY!
  • LIST ALLMEDICAL PROBLEMS. MOST IMPORTANTLY, LIST THE MEDICAL PROBLEMS THAT YOU HAVE FROM YOUR WEIGHT ISSUES (I.E. SLEEP APNEA, OSTEOARTHRITIS, REFLUX DISEASE, ETC.)
  • LIST ALL PRESCRIPTION OR OVER-THE-COUNTER DIET PILLS YOU HAVE TAKEN, HOW LONG YOU WERE ON THEM, AND RESULTS.
  • LIST ALL PHYSICIAN SUPERVISED DIETS, WHAT TYPE OF DIET IT WAS, HOW LONG THEY LASTED, WHAT THE RESULTS WERE, AND THE PHYSICIAN SUPERVISING THEM. PLEASE REMEMBER TO PUT IN DR.’S FIRST AND LAST NAMES OF THOSE THAT TREATED YOU!
  • LIST ALL DIET PROGRAMS SUCH AS WEIGHT WATCHERS, JENNY CRAIG, TOPS, ETC. YOU HAVE ATTEMPTED, HOW LONG YOU DID THEM, AND WHAT THE RESULTS WERE.
  • DESCRIBE HOW YOUR WEIGHT HAS AFFECTED YOUR LIFE PHYSICALLY AND EMOTIONALLY.
  • LIST THE REASONS WHY YOU ARE INTERESTED IN HAVING THIS SURGERY DONE.

IF YOU CHOOSE TO DO SO, YOU CAN TYPE YOUR LETTER AND INCLUDE THE REASONS YOU FEEL YOU NEED THE SURGERY AND WHAT THE WEIGHT IS PREVENTING YOU FROM DOING. YOU MAY THEN USE THE ENCLOSED DIET HISTORY FORM TO ENTER YOUR PAST ATTEMPTS AT WEIGHT LOSS.

DIET HISTORY

PLEASE BE AS DETAILED AND SPECIFIC AS POSSIBLE. THIS IS ONLY TO HELP US TRY AND GET YOU APPROVED THROUGH YOUR INSURANCE.

TYPE OF WEIGHT LOSS PROGRAM / NUMBER OF TIMES TRIED / HOW LONG DID YOU FOLLOW THE DIET / WHAT WERE THE DATES THE DIETS WERE TRIED /

RESULTS

WEIGHT WATCHERS
PHYSICIAN
SUPERVISED
DIETS
DOWN WITH
THE POUNDS
TOPS
PRESCRIPTION
MEDS
(4 WEIGHT LOSS)
BEHAVIOR
MODIFICAT.
PSYCHO-
THERAPY
(GROUP OR
INDIV.)
UNSUPERVISED DIETS
(SLIMFAST)
OTHER

Bariatric Surgery Frequently Asked Questions

The following information is provided in an effort to help educate our customers on the medically supervised dietary programs that are required prior to being approved for Bariatric (Gastric Bypass) surgery.

What does Blue Cross and Blue Shield of Alabama(and most insurance companies) consider a medically-supervised diet?There are two types of medically-supervised diets:

  • A physician-supervised program consists of nutrition and increased physical activity (including dietitian consultation, low calorie diet and behavioral modification). There must be medical record documentation of program participation by the attending physician of the organized program or the patient's primary care physician (PCP). Documentation should include patient's progress or lack of progress.
  • Participation in programs such as Weight Watchers, LA Weight Loss, Eat Right, etc. There must be medical supervision that includes visits to the patient's primary care physician (PCP), medical record documentation that the patient is attending a program, and status of the weight loss attempt.
  • Letters do not meet the documentation requirement for either method used as a weight loss program.
  • Medical records must be submitted along with the program records from the patient.
  • In some areas of Alabama, there is not a medically-supervised weight loss program available, and those that are available, are unaffordable.
  • Is it appropriate to see a physician and be placed on a diet?

Yes. Documentation of participation in a physician-supervised program of nutrition and increasedphysical activity (including dietitian consultation, low calorie diet and behavioral modification) mustbe presented in the medical record by the physician. Documentation should include comments by thephysician regarding patient's progress or lack of progress. There must be medical records to document

medically-supervised weight loss attempts. A letter does not meet this requirement.

  • What if a person works out of town during the week and is unable to attend a weight loss program?
  • If the person is unable to attend a medically-supervised weight loss program, they are unable to meet

Blue Cross and Blue Shield of Alabama's criteria for coverage of bariatric surgery.

  • How is a medically-supervised diet documented in the medical record?
  • Height and weight should be recorded with other appropriate vital signs. A statement from the physician should document the program that the patient is participating in and status of their weight loss attempt. This information should be submitted with the request for predetermination, or submitted if the claim is reviewed. In addition, any records the patient has obtained from other weight loss programs as specified in the coverage policy should be included.
  • When does the six-month weight loss attempt begin?
  • At least one attempt of a medically-supervised diet must be documented for at least six consecutivemonths in a one-year period prior to the request (predetermination) or date of surgery if nopredetermination is requested (i.e., January – July). Six months does not equate to six physician visits.The first physician visit or visit in a supervised weight loss program does not count as a month. Themonth of participation ends 30 days later.
  • For purposes of Blue Cross and Blue Shield of Alabamacoverage, what physicians can medically supervise the dietaryattempts to lose weight?
  • Family practitioners, internal medicine, and other primary care specialties such as OB/GYN canmedically supervise a patient's dietary attempts to lose weight.
  • Can the weight maintenance program be monitored by anassistant surgeon (M.D.) who is not performing bariatricsurgery?
  • No. Family practitioners, internal medicine, and other primary care specialties such as OB/GYN can

medically supervise a patient's dietary attempts to lose weight.

  • How does the bariatric surgeon document that the patient wasseeing another physician for medical supervision of weight loss?
  • The bariatric surgeon should list the name of the supervising physician. The records from thesupervising physician will need to be included in the predetermination request or when the claim isreviewed.
  • How frequently should visits be made to the physiciansupervising the weight loss attempt?
  • Monthly physician visits, or three physician visits during a six-month nutritionist-led interventionwould be sufficient for coverage purposes.
  • Example: If a patient's weight loss attempt is being monitored by the primary care physician thereshould be no less than monthly visits with documentation for six consecutive months.
  • If a patient's weight loss attempt is nutritionist-led, such as Weight Watchers, three physician visitsduring a six-month interval is sufficient along with the documentation from the Weight Watcher'sweekly visits.
  • Does the weight loss program have to be the same for the entiresix months or can the patient try different programs for sixconsecutive months?
  • The patient is required to be in any approved program for six consecutive months.
  • If a patient presents a documented three-year history of morbidobesity, undergoes the six consecutive months in a weight lossprogram under the supervision of their primary care physician,and actually loses enough weight to be below a BMI of 40 or 35with co-morbid factors, does this meet the criteria for bariatricsurgery?
  • A BMI of less than 40 or 35 with co-morbid factors does not meet the criteria for coverage of bariatricsurgery. These patients should be encouraged to continue with their successful weight loss program.If a patient met the criteria for BMI requirements five years ago, has lost weight and now the patient ismorbidly obese again with recent weight gain, is the review from five years or do we adhere to thethree-year morbid obesity requirement?
  • The condition of morbid obesity (BMI greater than or equal to 40 or BMI greater than or equal to 35with co-morbid conditions) must be of at least three years duration prior to being considered forcoverage. The three years is considered on the basis of consecutive time at levels of morbid obesity, nottotal time over extended periods. Any time a patient's BMI falls below the criteria threshold isconsidered a break in consecutive months. If in the future a patient's BMI again reaches threshold, anew three year period will begin.
  • Diabetic patients as a rule are on a diabetic diet that is a strictcaloric count. Can participation on a diabetic diet that has beendocumented in the primary care physician’s medical record beused as the six months of supervised weight loss period?
  • Morbidly obese patients on a diabetic diet with strict adherence in many cases would lose weight.Supervision of a diabetic diet does not qualify as satisfying the six-month weight loss attempt. Alldiabetic diets may not have a goal of weight loss. The support and goals for these two types ofprograms may differ and therefore are not interchangeable.
  • If a patient has Blue Cross Blue Shield coverage from anotherstate such as Tennessee, Mississippi or Georgia, does that state'sBlue Cross Blue Shield determine the criteria for bariatricsurgery?
  • The Blue Cross Blue Shield state where the member's contract originates is the Plan that determines thecriteria for coverage.
  • How many post-op visits are required in the first year?
  • Four to six follow-up visits within 12 months of surgery is appropriate.
  • What is the difference in a predetermination, a precertificationand a referral?
  • Predeterminations, Precertification’s and Referrals are all mutually exclusive of each other.Predetermination by Medical Review determines medical necessity based on coverage criteriafor planned procedures.Precertification by Health Management determines appropriate hospital/outpatient setting andlength of stay for procedures and/or admissions based on criteria.A referral must be obtained and/or submitted by the Primary Care Physician (PCP) forrecommended specialist or treatment based on specific contract language.Please refer to Customer Service to determine specific contract requirements.
  • Who do I call if I have additional questions?
  • You may call the customer service number on the back of your insurance card if you have additionalquestions.

How much does bariatric surgery cost?

Every insurance policy is different. There are several different policies for each insurance policy. For example, even though you and another patient may both have Blue Cross Blue Shield, each of your Blue Cross Blue Shield policies may cover the procedure differently. Our office verifies your benefits prior to your informational seminar and consults with Dr Mora. You will need to get in contact with your insurance company should you have any questions concerning coverage of your bariatric surgery. There are several estimates below to give you an idea of what to expect as far your costs. Remember that these are just estimates and not exact amounts. If the insurance has no bariatric coverage on the policy patient cost $2200.00 this is for Dr Mora services ONLY! All fees must be paid before surgery is scheduled. If a payment is by check, the payment must be made 10 days prior to surgery; otherwise payment can be made by cash, credit, or debit the week before surgery. All patients that have 50/50 coverage must pay for Dr. Mora’s portion of the surgery charges before their surgery. This specific amount being $1057.00, which is %50 of the “usual, customary, and reasonable” for Blue Cross Blue Shield of Alabama ‘s fee schedule-if a payment is by check, the payment must be made 10 days prior to surgery, otherwise payment can be made by cash, credit, or debit the week before surgery These costs do not include your seminar fee prior to your surgery, your initial office consult, and any other office visits you may have prior to surgery. Our office cannot quote charges, nor does the billing, for Prattville Baptist hospital or the anesthesia services provided during surgery. For specific amounts please contact Prattville Baptist Hospital and the anesthesia service directly.