How to Start the WLS Process?

[Sam.J.S. 5]

Hi! I am very new to this community and to the idea of WLS in general. I have tried (and failed) for years to lose weight, so I am finally reaching out for help! I am 24 years old, 5'5", and currently weigh 310lbs, putting my BMI at 52.

My question is... where do I even begin? I just made an appointment with my PCP for next week and said the reason for the appointment was to discuss my weight. I started weight loss management with her back in August 2020 (~6 months ago), so I do have some documented proof of trying to lose weight through diet change and exercise. But... it hasn't worked. I only lost about 15 pounds and have since plateaued.

I am now interested in my WLS options. How do I even breach this subject with my doctor? Do I just outright say I am interested in bariatric surgery? My health insurance (Harvard Pilgrim) requires a referral, so I know this is the first step to take, but I am not sure how to get the ball rolling or what to expect.

What can I expect out of this initial conversation? What was your experience like? Has anyone been denied a referral from their doctor?

Any advice or info would be greatly appreciated! Thanks in advance 🙂

[ms.sss 15,581]

First step is to tell your PCP that you would like to pursue WLS and ask them if they will give you a referral. If they don't, find another doctor who will.

From there your referring doctor and insurance will tell you what you need to do (different insurance companies will have different requirements).

This is exactly what I did with my PCP. I told him I want WLS, he said OK, and would submit his referral. Note, however, that I am in Canada, so its a little different, as WLS is covered by provincial insurance for those who qualify, but the process is essentially the same, just different institutional providers.

[catwoman7 11,212]

yes - start with your PCP. Many of them are very supportive of WLS. If yours isn't, find a new one, like ms.sss said.

[Suzi_the_Q 257]

I agree, just be direct about it. If your dr doesn't refer you, find a new one. At your BMI and with your wl difficulties, it shouldn't be an issue getting the referral.

[LoveSimcha 97]

I would also call your insurance company to find out what they cover and what their requirements are. Some insurance companies require documentation from your doctor that you tried other weight loss techniques. I would think your primary care doctor would be supportive but even if he or she isn't, you will want the records of the history of your weight. Good luck!

[Creekimp13 5,840]

My doctor was delighted I brought it up. He loved the idea and said he had several patients in his practice who had terrific results. He had an excellent recommendation for a Bariatric program, too.

[Jnfinney 526]

I went about this in a much different way. My doctors office and the hospital are all one big organization. I had talked to my doctor about my weight before, but he never seemed too concerned because I’m “not that big.” (Well I’m big enough to be uncomfortable doing day to day activities.) Anyway, I was looking into the weight loss program the hospital I go through offers. I noticed they had a questionnaire that could be printed, filled out, and sent back. The questionnaire was used to determine if you qualified to be part of the program. I though, well what do I have to lose? So, I filled it out and sent it in. Now 8 months later I’ve been approved for surgery and have a date set. I’m not sure if other places have a system like this, but I’m really glad I began looking out of curiosity.

[PolkSDA 116]

On 2/12/2021 at 6:30 PM, LoveSimcha said:

I would also call your insurance company to find out what they cover and what their requirements are. Some insurance companies require documentation from your doctor that you tried other weight loss techniques. I would think your primary care doctor would be supportive but even if he or she isn't, you will want the records of the history of your weight. Good luck!

I'm actually going to NOT recommend this. Insurance benefits and coverage are a potential minefield of complexities. To venture into this arena as a lay person is not for the faint of heart. If your PCP and (proposed) surgical facility are part of the same system, I would rely upon them and their insurance experts and resources to handle all if the minutiae. After all, that's part of the service you're paying for.

Only if you start getting pushback, denials, or nonresponse from the medical team, would I recommend getting involved with the process. At the same time, be aware of you medical insurance coverage, its deductibles, copays, in-network vs. out-of-network coverage. Once you are approved, ask what your out-of-pocket costs will be and make sure they align with your understanding of your medical coverage obligations.

In my case I was NEVER involved in the insurance approval or documentation process even once. I never had any direct contact with my insurance company. The bariatric medical team/department handled all of the paperwork, the application and approval process, everything. My only involvement was after the fact when I got the bill for my copayment ($375 surgical copay was the only cost I ever incurred outside of $30 physician visit copays).

12 minutes ago, Jnfinney said:

I went about this in a much different way. My doctors office and the hospital are all one big organization. I had talked to my doctor about my weight before, but he never seemed too concerned because I’m “not that big.” (Well I’m big enough to be uncomfortable doing day to day activities.) Anyway, I was looking into the weight loss program the hospital I go through offers. I noticed they had a questionnaire that could be printed, filled out, and sent back. The questionnaire was used to determine if you qualified to be part of the program. I though, well what do I have to lose? So, I filled it out and sent it in. Now 8 months later I’ve been approved for surgery and have a date set. I’m not sure if other places have a system like this, but I’m really glad I began looking out of curiosity.

In my case it was when I was diagnosed with (early stage) type II diabetes in June of 2019, following having been on high blood pressure medication for several years. I figured that at age 53 I was living on borrowed time if I didn't make some rather drastic changes... I'd kinda like to live to see retirement.

I had looked into weight loss surgery in 2000 or so, but it was still relatively new, the options were limited, and the complication rate was MUCH higher. So I told my PCP that I was potentially interested in weight loss surgery and would like to re-explore options. He referred me to the bariatric department. I had an initial exploratory meeting with an LPRN, and once we tentatively determined that sleeve gastrectomy was the best option, they set me up an introductory meeting with the surgeon. Only after that consultation and pre-surgery weight loss goals had been determined did they initiate insurance approval.

As was explained to me, the biggest factors in the approval process are BMI and comorbidities (exacerbating medical conditions). In other words, if your BMI is above X you have the best chance of approval, or if your BMI is X-10 but you also have an additional medical condition(s) (diabetes, high blood pressure, , etc.). So it can be somewhat of a sliding scale and will likely vary by insurance company.

What followed was a 6-month+ process of meetings with dieticians, the surgeon, a full psychological evaluation, and proven attempt to lose weight even before surgery is scheduled. My surgery was originally scheduled for April of 2020, but COVID intervened and it was canceled, ultimately occurring in July of 2020.

Lemme tell ya, trying to maintain a weight-loss/healthy(ier) way of eating while the world and society is collapsing around you and being prone to "stress eating" ain't fun. Remember, in March/April of 2020 we didn't yet know what direction the pandemic would take... this was the time of panic buying, overreaction, and just general freaking out. Our department started working remotely on March 17, 2020 and we were still adapting to the world of Zoom meetings.

Looking back on things, I'm surprised things worked out... now I'm a heck of a lot lighter... and STILL working from home.

[Sam.J.S. 5]

Thank you all for your advice! I really appreciate it 🙂 I have an appointment tomorrow with my PCP and I am hoping she agrees this is the best option for me.

As far as insurance goes, I reviewed my benefits so I am aware of out-of-pocket costs-- but I may follow PolkSDA's advice and leave the details to the doctor's office team (as I'm sure they know more about that process than I do).

Thanks again!

[ms.sss 15,581]

23 minutes ago, Sam.J.S. said:

but I may follow PolkSDA's advice and leave the details to the doctor's office team (as I'm sure they know more about that process than I do).

Just a suggestion: perhaps you may want to get involved in the details just so you are informed? The payment/coverage contract is between you and your insurance, not between you and the doc. Your surgeon is not held accountable for any promises they make you regarding coverage and reimbursements, if in the potential case of misunderstanding between surgeon and insurance. Your insurance will not accept "well, that's what my surgeon told me".

[PolkSDA 116]

Keeping informed/copied is one thing, but IMO I would not "get involved" with direct communications with the insurance company unless needed. You may inadvertently agree to something without realizing its ramifications. Let the medical team handle the direct correspondence. They know this industry; you don't. The last thing you want is for the insurance company to come back after the fact and say "on date xx-xx-xxxx you agreed..." when you had no idea you were agreeing to anything.

The language/nomenclature of both medicine and insurance are jargonistic and complex. Getting involved unnecessarily could either delay the process or at worst upset the apple cart.

The internal billing, fees, and writeoffs for the procedure and all the lead-up and after-care will contain a zillion transactional amounts, some likely not resolved until months after the procedure. Getting involved and asking "what is this line item?", "what does this term mean?", "why is that there?" is likely to not be productive.

At the end of the day, what matters are your personal out-of-pocket costs and obligations, and it is fair to ask the medical team to keep you apprised of any decisions that change those personal costs, but to get involved in the transactional details is going to be an exercise in futility... for all parties concerned.

[LoveSimcha 97]

1 hour ago, ms.sss said:

Just a suggestion: perhaps you may want to get involved in the details just so you are informed? The payment/coverage contract is between you and your insurance, not between you and the doc. Your surgeon is not held accountable for any promises they make you regarding coverage and reimbursements, if in the potential case of misunderstanding between surgeon and insurance. Your insurance will not accept "well, that's what my surgeon told me".

This exactly. The more informed you are - the better off you are. The surgeons will make you sign "In the event my insurance does not cover a procedure, I agree to pay". The surgeons office is a great tool and yes they will assist in many ways but IMO it is always better to be informed.

[ms.sss 15,581]

51 minutes ago, PolkSDA said:

Keeping informed/copied is one thing, but IMO I would not "get involved" with direct communications with the insurance company unless needed. You may inadvertently agree to something without realizing its ramifications. Let the medical team handle the direct correspondence. They know this industry; you don't. The last thing you want is for the insurance company to come back after the fact and say "on date xx-xx-xxxx you agreed..." when you had no idea you were agreeing to anything.

The language/nomenclature of both medicine and insurance are jargonistic and complex. Getting involved unnecessarily could either delay the process or at worst upset the apple cart.

The internal billing, fees, and writeoffs for the procedure and all the lead-up and after-care will contain a zillion transactional amounts, some likely not resolved until months after the procedure. Getting involved and asking "what is this line item?", "what does this term mean?", "why is that there?" is likely to not be productive.

At the end of the day, what matters are your personal out-of-pocket costs and obligations, and it is fair to ask the medical team to keep you apprised of any decisions that change those personal costs, but to get involved in the transactional details is going to be an exercise in futility... for all parties concerned.

...and that's cool too.

To the OP, do whatever you feel comfortable with...take whatever suggestions YOU feel is in your best interest, and leave the rest.

Good Luck! ❤️

[bufbills 316]

I would call your insurance company. They will tell you if it is included in your coverage. Doing this, will keep you from wasting time, and worry. Excellent place to start. You pay them, and they are there to help you.

[blackcatsandbaddecisions 851]

The insurance company is bound by a contract, either between you and them for direct pay, or more likely between an employer and them to provide certain types of care. There’s no risk in calling them, there’s nothing to inadvertently agree to. All they can do is provide information on contracted plan benefits.

In the end you need to take responsibility for your own finances and you should confirm everything with insurance yourself. I work with both health care and insurance and it’s vital to have a personal understanding of your plan benefits and how it will impact you. When I called I asked

1. Is bariatric surgery covered? Is there a prior authorization requirement? Can you share with me the page of the plan document that outlines these prior authorization requirements?
2. Are there requirements to see a surgeon/hospital within the plan network, or certain providers in order to receive coverage?
3. Is this subject to the deductible and coinsurance or are there special provisions for this coverage?

Hopefully your surgeons office will help you with this, but I never recommend being passive and trusting someone else to do something when there’s tens of thousands of (your!) dollars on the line.