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After making the deeply personal and often difficult decision to undergo morbid obesity surgery, generally the next critical issue to confront, and perhaps the single largest stumbling block to having surgery, is how to present the claim to your insurance company, HMO or self-insured plan and get them to say "Yes" to the request for pre-certification.

This is the first in a series of articles in BEYOND CHANGE intended to assist both patients seeking surgery and the health care professionals who often submit the initial requests on behalf of their patients.

This first article should be considered by many to be the "Basic Course." While subsequent articles in the coming months will devote substantial time to very unique and difficult insurance issues, the purpose of this article is to provide some fundamental guidance to both patients and practitioners who want to get insurance claims approved the first time! So with all needed attribution to David Letterman, here is my "Top Ten Things You Can Do To Get A Surgery Approved List":

10. GIVE THEM THE TOOLS! Provide your surgeon's office with the armor they need to fight the fight. It is YOUR JOB as the patient to gather that material together your surgeon's office may be able to help some but it is ultimately your responsibility. That "armor" includes: relevant medical records which document any co-morbid conditions you have such as diabetes, sleep apnea, hypertension, acid reflux and the host of other health problems we face. If you've been on medically-supervised weight loss programs or have been on medications, get those records! If you're not sure they will help, think of this as chicken soup --- "It can't hurt!"

9. USE THOSE TOOLS! For the surgeons' office: once given that information your patient has worked so hard to provide to you USE IT! I cannot count the number of inadequate preauthorization letters I've seen which fail to contain very elementary information and supporting records. Your preauthorization letters MUST include a height and a weight. (Believe it or not in many obesity surgery appeals we've seen plenty of doctor letters that don't include this most basic information!) You should accurately calculate the patient's Body Mass Index (BMI). You should specifically identify all comorbidities for which the patient is being treated and include ICD-9 coding for each of those conditions. To the extent possible, and especially in "managed care" environments, you should include chart notes and records from a primary care physician. And it should all be sent by some means that can be tracked and must be signed for so you can avoid, as much as possible, the inevitable "but we never got your request" so many of us hear from insurers.

8. MORE TOOLS ARE BETTER TOOLS! Patients should try to gather together all the available records from their commercial weight loss efforts such as Weight Watchers, Jenny Craig, Diet Center, etc. Although these are difficult to get in many instances, these records can sometimes substitute for the required "medically supervised" diets that insurers routinely require.

7. SUPPORT GROUPS ARE KEY! Patients can go to support groups before surgery. There is no better place to gather important information about your insurance company than from people who have "been there done that." Maybe it's the name of a claims person with ABC Insurance Company that understands and is sympathetic to morbid obesity surgery that you get in order to send your packetmaybe it's the secret company form that needs to be filled out just right to secure the referral.maybe it's the name of a PCP who, unlike the one you have now knows, understands and supports your efforts to have surgery. All of this and so much more can be obtained from support group.GO!

6. TAKE CONTROL! Patients should take responsibility under the guidance and direction of your surgeon's office for doing the follow-up on the insurance submission. Remember that you must actively participate in your healthcare and that means contacting the insurance company to get a response or to provide answers to questions or give more information. (Now remember that there is a line between appropriately "following up" and "stalking" your insurance company!) While you must give them a reasonable amount of time to assess your claim (30 days is not unreasonable), you have every right to insist that a decision be made as soon as possible AND to know exactly what the decision is and WHY (especially in cases of denials).

5. DOCUMENT DOCUMENT DOCUMENT!!! Both patients and practitioners need to be aware that telephone conversations never happen unless they are followed-up by a letter.verbal requests for coverage aren't valid you need to GET IT IN WRITING! If an insurance company person gives you important information on the phone, get their name, their address and write them a little ol' letter confirming what they told you. Many surgeon's offices keep a separate "insurance conversation log" in patient charts to note conversations regarding the approval process. That is good practice but sending confirming letters for important calls is even better!

4. KNOW YOUR OPPONENT! Every insurance company that covers these procedures has certain protocols that need to be followed to get that approval. Some need the psychological consult before the approval if so get it! Some need the dreaded diet history give it! You don't want to unnecessarily delay a surgical approval by not providing information you know a company requires get it right the first time so there is no second time!

3. USE YOUR TECHNOLOGY! This is the "Technology Age" the Age of Information. There are vast amounts of information on the Internet websites and chat groups and email support lists all related to bariatric surgery. This information can be used by patients and programs alike to do research on procedures, insurance companies and talk to pre-and post-operative patients. But remember! Just as the internet can be used for good it too can be used for evil! There is a great deal of misleading information, partially correct information and just plain ol' WRONG information out there on both surgeons' sites and other sites trying to be helpful so be careful out there and don't be afraid to question and confirm what you hear on the 'Net..there is no substitute for in-person professional advice from your medical providers.

2. BE CAREFUL ON APPEALS / GRIEVANCES! If you get that dreaded "no" to the surgery request all is not lost but you must proceed cautiously. While appeals and grievances are subjects for future articles for BEYOND CHANGE in and of themselves, a few words to the wise. Get your coverage booklet out and know your rights. Surgeons and patients alike must remember that you only have so many appeals available be careful not to use them all before seeking out assistanceyou may run out of options before you know it!

AND THE NUMBER ONE THING TO DO TO GET A SURGERY APPROVED IS..

1. BE TENACIOUS! Too many people let insurance companies win the battle and the war because they give up too soon or they look at their policy, see an "exclusion," and never try to fight. Big wars and little wars are being fought and won everyday. You are seeking or providing a wonderful tool in the fight against morbid obesity. There are many obstacles to getting that tool, but there is no substitute for hard work and never ever giving up! If you can do that the results can be GLORIOUS!

GO GET 'EM!!!