So You’re Thinking About Bariatric Surgery

FIRST, A DISCLAIMER:

I am not a medical professional, nor do I claim to be.  I am also not a mental health professional, nor do I claim to be.  That said, I am a healthcare consumer, just like the rest of you, and I am sharing the experience I had going through the process of having weight loss surgery.  Your experience will likely differ.

For those of you considering weight loss surgery, I want to be sure to lay out some things you will need to consider as you explore surgical options for helping you to lose weight.  I’ll tell you what my experience was, and then let you know other ways that each of these things can be addressed or investigated.

This page will cover four main immediate concerns prospective WLS patients have:

  • Finding a Surgeon
  • Prerequisites for Surgery
  • Time
  • Cost

FINDING A SURGEON

I first asked my primary care physician about WLS, and she gave me the name of a surgeon she was familiar with.  I did my research and looked at three different surgeons, one of whom was the one my PCP recommended to me.  One of the surgeons I considered was a guy whose seminar I’d previously attended and which was more sales pitchy than anything else.  The surgeon I eventually decided to go with is one of the country’s experts on surgical treatment of obesity, and a really awesome doctor.  His seminar was more educational, as he led it and discussed why diets fail, how and why bariatric surgery saves lives, and the different procedures he performs.

Some folks find their surgeons by simply asking their insurance companies which doctors are in-network.  This assumes that the insurance policy the prospective WLS patient includes bariatric surgery as a covered benefit.  And some folks find their surgeon through word of mouth, or by doing research on their own.

I recommend that no matter how you go about choosing a surgeon, approach the process like so:  you don’t buy the first car, house, or engagement ring you go shopping for, so don’t choose the first surgeon you read/hear about or see that sounds awesome.  Have a set of criteria that your prospective surgeon should meet.  These will vary depending on what you’re looking for.  The criteria I established were chosen because for me, they were non-negotiables–if a prospective surgeon didn’t meet one of the criteria, they were automatically excluded from consideration.  These were my following requirements for a prospective surgeon:

  • Practice was limited to bariatric surgery ONLY.  I didn’t want a general surgeon who dabbled in WLS as a side job.  If the surgeon’s practice was not exclusively bariatrics, I excluded them from consideration.
  • No disciplinary infractions or malpractice complaints filed with the Texas State Board of Medical Examiners.
  • Practiced at designated Centers of Excellence (per BCBSTX rules) and was a designated CoE.
  • Worked with a team of professionals to provide patients with excellent aftercare.
  • Could do my surgery at a hospital close to my home so that long-distance travel was unnecessary.

The surgeon I chose met all of these criteria, and is a nice man who genuinely cares about improving people’s health through WLS.  SCORE!

I also wanted my prospective surgeon to have a competent office staff, an office that was close to my home, and to have a good rapport with patients.  Again, my surgeon met these requirements too which was a nice bonus.

Your criteria may be different, but those were mine.  But think carefully about what sorts of requirements the person who is going to cut you open and alter your GI tract forever should have.  You’ll have to go back to them over and over during the course of your lifetime, so make sure the person you choose is someone you can trust with your health, and who genuinely cares about your health and well-being.

PREREQUISITES FOR SURGERY

These may vary, depending on whether or not you are self-pay or are relying on insurance to cover the costs of your surgery.  The prerequisites for surgery may also depend on what your insurance company requires.  My insurance policy required the following things:

  • That my BMI was 35 with at least 2 comorbidities, or 40+ with no comorbidities.  I had no issue meeting either of these, sadly.
  • That I attend an informational seminar.
  • That I have a consultation with the surgeon.
  • That I had a documented history of obesity (at least 5 years of documentation) as well as documentation of previous weight loss attempts.
  • That I have a Letter of Medical Necessity (LoMN) from my surgeon to the insurance company stating why bariatric surgery was necessary for me to have.

Once I met those criteria per the insurance company, I waited for approval.  I was approved in less than a week.

Some policies require a 6-month medically supervised diet.  Some policies require that you be on that medically supervised diet for an even longer period of time.  Some policies require attendance at nutrition classes.  Some policies require a certain number of visits with a dietician.  Every policy is different so be sure to check your policy to see what is required.

Be aware that in order to generate a LoMN, your surgeon’s office may have you complete other tasks, such as:

  • A sleep study to rule out sleep apnea.  I had to have two.
  • Lab work, such as blood chemistries.  I did not have to have lab work done before my consult or before my LoMN was written; the surgeon’s office used what was in my medical history sent by my PCP, which was extensive.

Also be aware that each of these things incurs their own cost, which may or may not be covered by your insurance.

Folks who are self-pay may not need to meet all the same requirements and are often fast-tracked into surgery because of this.

My surgeon required me to undergo pre-surgical testing prior to surgery to establish baseline blood chemistries, cardiac function and GI function.  This involved:

  • Baseline blood chemistries and urinalysis
  • An EKG
  • An upper GI series

Instead of the upper GI, some folks have what is known as an EGD–esophageal dilation–a bit fancier and more involved than an upper GI, and definitely more expensive (around $17,000 in this area) as anesthesia is required.

He also requested that I meet with a dietician prior to surgery so that I understood what my nutritional requirements would be during the pre-op period, and how they would change post-operatively.   This was not a requirement, but I did it anyway so I would be fully prepared for what I was about to do.

I also had to meet with a nurse from the hospital where my surgery was done to review the procedure I was going to have done, and to discuss my wishes in the event that something horribly wrong happened during surgery and I was rendered unable to make my own decisions regarding my healthcare.  Prior to this meeting, I had an attorney help me draft medical power of attorney and living will paperwork so that I was covered.  Be aware that the facility where you elect to have surgery may require you to have this paperwork at your pre-op admission meeting (if you have one); mine did.  Had I not been in possession of this paperwork, the hospital had ready-made forms for this, but I wanted mine to be more specific so an attorney’s help was necessary.

Finally, I had to adhere to a low-carb, high protein pre-op diet that lasted 3 weeks.  This was the diet my surgeon required so that my liver’s glycogen stores would be greatly reduced by the time I had surgery.  I was required to have 2-4 protein drinks each day, plus one “lean and green” meal of lean meat and non starchy vegetables.

TIME

There are several time-related issues where having WLS is concerned:

  • How long does it take to get approval to have surgery?
  • How long did it take after approval to schedule surgery?
  • How long will I be in the hospital?
  • How long is my recovery going to be?

I’ll answer the first question:  How long does it take to get approval to have surgery?

Once I’d completed all the preliminary hoop-jumping, and my surgeon’s office had submitted my paperwork to my insurance company, I was approved in less than a week, which is relatively fast.  Some folks wait weeks and weeks.  If you have already started the process, and are anxious to see if you have been approved, call your insurance company and ask to see if your request has been approved.  You won’t know until you ask.  Thankfully, I was approved quickly but I know this isn’t the case for all folks.  Some people are denied the first time their doctors submit paperwork.  If you are denied upon first submission, appeal.  Find out why you are being denied, and find out what needs to be done to get approval.  Your surgeon’s office will be critically important here so make sure that they code everything properly and submit all the documentation necessary so that the insurance company can review the request again.  Sometimes people are denied a second, and even a third time.  Be persistent–this is your health, and it is worth fighting for.

The second question:  How long did it take after approval to schedule surgery?

I could have scheduled my surgery for April if I had wanted to.  But I wasn’t ready.  I still had questions and I still had homework to do.  Because of this, I requested a second consult, which I got, and at the end of that appointment I scheduled my surgery for the summertime as there was no way for me to take the time off I would need to recover in the spring.  Some folks schedule their surgery for a couple of weeks after they get their approvals, especially if their surgeons require a lengthy pre-op diet.  It just depends on what your surgeon requires of you immediately before surgery.

The third question:  How long will I be in the hospital?

This varies by facility, by surgeon, and most importantly, by how you respond to the surgery.  I went into the hospital at 7:30 am on a Monday morning, and was discharged the next day at 2:45 pm.  I wasn’t even there 36 hours.  I had a very smooth recovery and could walk and sip fluids with no issues.  My pain was also manageable.  Your doctor may require you to stay two days.  It all depends on how you respond to the surgery, how you recover from the anesthesia, and whether or not you are able to swallow fluids immediately post-op.

The last time question:  How long is my recovery going to be?

This also varies.  I was fortunate in that my recovery was pretty smooth and without incident.  I felt very tired the first few weeks, but around week 5, I started feeling much more like myself, and had much more energy.  For some folks, they feel better sooner, and for some it is much later.  This is a tough question to give an accurate answer to simply because every body is different and will respond to major surgery in a different way.  I also had no complications, thus my recovery was smooth and relatively short.  Should you have complications, your recovery time will obviously be much longer, but this will vary depending on what the complications are.  Again…your mileage may vary here.

COST

This will depend on what part of the country (or world) you are in, and whether or not you are using health insurance.  Remember that healthcare costs vary based on what geographical region you are in.  The Dallas area is home to many bariatric clinics and is known to be one of the more affordable places in the US to have bariatric surgery.  Of course after you see what my insurance company was billed for my surgery, you may think otherwise!

Many insurance plans do not make allowances for bariatric surgery, but this was not the case for me.  My insurance policy through Blue Cross Blue Shield of Texas (via the Teachers Retirement System) includes bariatric surgery as a covered benefit.  However, my policy has  a $5000 co-pay in addition to any other costs that must be paid.  This co-pay was over and above my deductible, which for the 2012-2013 plan year was $1200.  My out of pocket maximum was $2400, so any costs I incurred over and above that were covered at 100% by my insurance company.  Your insurance is likely different so be sure to read your benefits booklet closely to determine whether or not your policy includes bariatric surgery benefits.

If you’re all about numbers, then here’s what my surgery really cost.  I’m going to include the cost of everything leading up to the surgery and the surgery itself to provide as accurate a number for you as possible.  I know it’s not polite to talk about money, but let’s face it…medical care is expensive.  You are likely considering WLS because you want to avoid larger healthcare expenses down the road–I know it was one of the things that drove me to have surgery.  The way I saw it, I could pay for bariatric surgery now, or pay for a heart attack or stroke later.

Keep in mind, I had met my deductible in February 2012 with the first sleep study I did.  My insurance plan also pays at 80/20 so the costs you see are what I was financially responsible for.  I’ll put what my insurance was billed in parentheses.

Item Cost
Informational Seminar with Surgeon Free
Sleep Study #1 $623 ($3500)
Neurologist (sleep doctor) $32 ($400)
Sleep Study #2 (titration) $109 ($3600)
Neurologist (sleep doctor) $33 ($425)
CPAP machine and supplies $213 ($4292)
Surgical Consult #1 $39 ($321)
Psych Evaluation $61 ($384)
Surgical Consult #2 $23 ($155)
Dietician Consult $50 ($0)
Pre-op Exam with PCP $45 ($405)
Pre-op Lab Work $13 ($578)
Upper GI series $107 ($638)
Radiologist for upper GI $11 ($148)
Internist at Hospital $46 ($350)
Pathology services (liver biopsy) $163 ($1502)
Pathology services (stomach) $3 ($53)
Surgeon’s Fee $1572 ($30300)
Surgeon’s PA $0 ($7450)
Anesthesiologist $2125 ($4250)
Internist at Hospital $19 ($124)
Hospital room and care $851 ($42897)
TOTAL $6138 ($101772)

You can see why some folks elect to self-pay.  You can also see why many insurance plans do not include bariatric surgery as a covered benefit.

Because many insurance policies do not cover bariatric surgery, many people are self-pay patients.  As a result, many bariatric patients have their surgery in Mexico, where the cost is much lower than here in the US.  Be aware that if you are insured, decide to have your surgery in Mexico as a self-pay patient, your insurance company may not cover any medical costs you may incur as a result of your surgery after the fact.  So for example, if you have surgery in Mexico, come home afterwards and then spring a leak, your insurance company may not cover the cost of your medical treatment on this side of the border since your original procedure was not performed in the US.  Check with your insurance company.

Also be aware that there are many folks who do elect to self-pay and go to Mexico to have their WLS done there who have had no issues receiving follow up care from their own doctors.  Should you decide to pursue surgical options in Mexico, check with your own doctors to see if they are willing to take on your aftercare.

I am not including the cost of protein drinks, powders or nutritional supplements.  These costs will vary widely as there is no standardization of post-op nutrition from surgeon to surgeon.  If I had to estimate how much my protein supplements cost, I’d say for the 6 solid weeks that I was drinking protein drinks the cost was roughly $300 (3 weeks pre-op and 3 weeks post-op).  This includes samples of protein powders and drinks that were tried before surgery to determine which ones I liked because I knew I was going to be drinking them for a while.

I hope this primer has been helpful.  If you have questions, leave a comment and I will answer it the best I can.  You can also check out the forums at ObesityHelp.com as there is a wealth of information there too.

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2 responses to “So You’re Thinking About Bariatric Surgery

  1. Your surgeon billed BCBS $30,000? That’s insane. I’m curious what BCBS actually paid the surgeon. Mine billed $4,000… and insurance paid $1200 or so.

    • Yup, they did. I’d be curious to know what he was paid by them too. He has a pretty high patient volume–since last year, two more surgeons have joined his office, and they’re always busy.

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