Advocate Medical Group in Illinois (Chicago area) Surgery Requirements

     So, I am currently in the process of starting my journey to receive weight loss surgery! I'm optimistic but nervous about the hoops i'll have to jump through to get the surgery. This would be my second time around trying to get the surgery as well. As of now I am with BCBS in an HMO, which means I can't move without my referrals for surgery appointments, etc. I have been with my PCP for about a year now and she is aware that I do want WLS. She planned for me to start a diet/exercise regimen for 6 months and to come in and do monthly weigh ins to track my progress. Which at first started off fine but I didn't make my monthly appointments for weigh ins because I kept starting and falling off of my diet plans, getting discouraged, and not losing weight! I am consistent in trying to focus on eating healthy and now exercising yet I'm also consistent in falling off the band wagon. Which is why I need this surgery! At this point in my life I am at my heaviest and I know that once I get this surgery, it will be the tool necessary to help me get to my goal and live my life. 

    So, I went to my doctor and asked for a referral to meet with the surgeon and get information on the requirements. SHE REFUSES TO GIVE IT TO ME until I do the 6 months of the weight management and weigh ins. So, I called my insurance to see if that's a requirement for approval and they said its based on the PCP medical group of Advocate to state what requirements they want to submit to the insurance to show medical necessity for the surgery. So, of course my next thought is to change PCP and medical groups to a provider who would at least be willing to give me a referral to meet with the surgeon! So, I said all this to ask does anyone have any experience with Advocate Medical Group in IL or has gotten their surgery with an Advocate WL surgeon?? Are submission approvals for insurance based more so on what the PCP states or the surgeon? Should I just go into my PCP appointments to weigh in even if I'm not losing weight to document that doing this on my own isn't working for me? Or are the weigh ins specifically necessary to show that your are progressively losing weight as evidence that you will keep it off after the surgery?? Any info on this would be greatly appreciated! Thanks!

BTW I have a BMI of 60 with no co morbidties unless depression and shortness of breath count!

I hope this helps.  I am 16 months post-WLS but I still recall feeling determined (and desperate) to get the surgery.  I did not need to go through my PCP but, like you, I don't think I would have stopped just because she gave me a "NO."  If there is anything you do not understand, please ask me.  I can see a few ways for you to proceed.  Other people here may have ideas also.

You can start two tracks at one time - you can attend public info meetings for several surgeons in your area. See below for link. The surgeon's office is actually the one who submits your paperwork for ins. approval. Go to a couple of meetings and find the one or two that you click with.  If you need to change PCP's I would ask your favorite surgeon who they would recommend.  They will help you negotiate the insurance maze.  You do not need a referral to attend the public info meetings and many will meet with you for a consult for free.  At the end of the public meeting, the office staff will be there - ask and set up an appointment. From my understanding, your PCP is just a ticket to get punched and the surgeon is really calling the shots (because it is the surgeon who wants to get paid for doing the surgery, not the PCP).  You will have other tickets to get punched, so get used to making lists and following instructions.  But those 6 months will go by.  The healthier you go into surgery the healthier you come out. 

That being said, I am concerned about one of the things you write:  Why do you not go to the 6 months of meetings with you PCP - because you gained a few pounds? You might not lose every time you weigh in, but you need to go in, get your ticket punched, listen to another lecture or whatever ideas your PCP might have.  Any issues you work through before surgery - emotional eating, binging, etc - will make your recovery from surgery and WL that much better.  For me, I was a total diet failure - in the 3 years leading up to surgery I lost 120 pounds only to gain 110 back.  When my doctor told me to lose weight before surgery, I almost screamed at him - WHY BOTHER, IT WILL ONLY COME BACK ON.  Then I realized - No that is why I am having the surgery.  The promise of having the surgery did help me make better decisions during the pre-op phase, and I hope you find what you need to find to make it through all the pre-op hoops.  It was much better for me after surgery, but you will need to keep you eye on the long game - both before and after surgery.  Surgery makes it easier to lose weight, but one can still fall off the wagon and regain.

If I understand what you write, you did not complete the 6 months, so of course your PCP would not give you a referral - you did not follow her instructions.  On the plus side, there is not a lot of data (perhaps, none) that being put on a 6 month pre-op diet will help your postWLS weight loss.  If you do not follow directions, however, your health or life may be at stake after WLS. IMHO, some of this is just a test to see if you can follow directions.  In addition to the (arguably unnecessary) pre-op diet, some insurance co are now trying to make a pre-op EXERCISE PROGRAM - like with a trainer a new requirement. OK, enough about the hoops you will go through - you will get through them.  And in a year from now, you will be writing a post like this to someone who is just starting.

About your pesky PCP - what type of support did you get from your PCP to help you lose weight?  Did you get more than a paper diet?  Do you need a PCP who has better insight into wt management?  If so, change now, because even after WLS you will need a PCP with insight on how to support someone with weight challenges - these issues do not disappear just because of WLS, although they are MUCH MUCH more manageable and at a lower weight.

It seems like you have a few options - find a new PCP and start over OR try again with the one you already have. Is your PCP any good for the other things you see her for?  If I were going to change PCPs for someone who has a better insight into weight management, I would go to the surgeon's public info meetings and get input on PCPs who have a better understanding of the weight issues.

Here is the link for the FREE public info sessions given by your Advocate Health bariatric surgeons.  At the meeting, I would not go into too much detail about your problems with your pesky PCP, just say that you have discussed WLS with your PCP and want to know more about it. (When you meet with the surgeon, I would suggest you check if the surgeon might be able to manage your 6mo pre-WLS diet program, and then you go back to your pesky PCP.  My surgeon does this, but he has been focusing on WLS for over 15 years so he has a good understanding of how to help patients, not just be a pain in the @$$)  

For the info meetings in your area: https://healthadvisor.advocatehealth.com/classes

Where is says TYPE, scroll down to Weight Management and hit search a list will pop up.  Click on the  

 link to see the times, locations, and dates for the meetings.  There is one next week.  You can make and appointment, or do what I did - slink out and think it over for a few weeks and then go to another meeting or call the office for an appointment.

Also, you might be able to go to surgeon's outside of the Advocate Health Network, but that depends on your insurance.

As a WLS patient, I think that some of the pre-op requirements are just to delay and deter, but we have to do them.  A last bright side -you live in a state when WLS is covered by insurance (most do not). 

IMO This is pre-op sh!# is a game - get in it to win it.
Best wishes for your journey.

^^^This is EXCELLENT advice.^^^

To add -- I went to weigh ins EVERY month with my PCP while attending seminars and weight-loss informational programs with surgeons.  DO NOT SKIP your documentation just because you've not been successful that month.  

No one is perfect with their pre surgical weighins and diet in the six months with your primary or how many months you need to do it. It is about going for the documentation and learning new eating habits and life style changes. I feel the doctor was correct in not giving you a referral. You need to show follow through. If you cannot follow through with this then how are you going to follow through with the rules PO? And believe me the PO life is not easy. Many people in the outside world think it is the easy way out but it is not.

Good luck with your journey. It seems like the wait at this time is very long but it will go fast and it is oh so worth it!

PS edited to add that my husband's BMI was the same as yours and he had to jump through a lot of hoops and was denied by his insurance company in the process. He had to wait just as long as you have had to wait. He is almost 13 years PO and is still down 190#.

   First off, I have to say Sharon..THANK YOU SO MUCH for your in depth and thoughtful response! I appreciate it more than you know because it definitely given me more insight on potential routes to take in being proactive in my surgery journey! And yes I refuse to stop based on on a one NO! I understand that on my behalf that it is my lack of discipline in being diligent in following up with my PCP so I am going to make it a priority to get in, weigh in, and get on with my life! 

As for my PCP, I do like her and feel she is a good doctor but I honestly don't know her history with working with patients who are seeking WLS and have gone through the process. When I was doing research for my PCP she appealed to me because one of her specialties is weight loss management, among other things. As far as what tools she's given me for weight loss: All she gave me was information for a Very low calorie weight loss program where you substitute regular food for supplement meals and snacks and you meet with a group and a doctor weekly to track progress. Which, initially I was all for because I love the idea of the weekly tracking but once I went and found out how much it would cost WITH the insurance I realized it was out of my price range. So, I've just been doing stuff on my own. So, I know ultimately I will have to switch PCP doctors to someone who support me before and after surgery.

 So, I definitely will be taking your advice on going to the WLS seminars and seeking free consults as well! I did check out the link and I've actually heard of those surgeons listed so I look forward to speaking with one or all of them in person.

Mini-Update: So, I actually had a doctor's appointment today, I initially was going to meet with my PCP but she didn't have an appointment available that worked with my schedule so I opted to meet with another doctor in the office (Iv'e met with her before as well) and I explained to her that I want to meet with the surgeon as to have a more cohesive plan for my Pre-Op requirements and to start my relationship with my future surgeon and GET THIS BALL ROLLING!! So, she agreed with me and decided to put the referral in for me!  

Although, she did inform me that the referral has to approved first from the referral team. She stated that the referral approval will be based on finding a surgeon that accepts my insurance and seeing if I'm a candidate for the surgery. So, fingers crossed for the referral approval! She said to call back at the end of the week to check in if they haven't called me first. I'll keep you all posted!

I never met my surgeon until 6 weeks before surgery. I had many many hoops to jump thru including 6 months diet, nutrtionalist, behavioral therapy, nutrtional therapy. Forgive me if I am wrong but I get the impression you think surgery is the answer all. It's just a tool. 6 months is minor in comparison to the rest of your life having to be conscious of every bite. It's hard. Your PCP saw the red flag. Start over and jump the hoops, you can do it !

Kathy you're definitely forgiven! lol Seeing that I've been obese all my life and in relation to plenty others who have experienced the same I've utilized a multitude of tools in my journey to a healthier life. At times I've had more success with these tools than others. Yet, in no way do I feel that having this surgery will be the answer to the problem. In relation to the other tools that I've used, surgery is the one tool that carries the most risk yet at this point in my life I'm definitely ready to take that risk. Hence, as to why this is my 2nd time around because initially I was not ready. Again, the sole purpose of getting the referral, in my case,is to meet with a surgeon and get information not to avoid surgical requirements  I'm definitely prepared and aware that this process is going to lengthy and rough, nonetheless I have no intentions of stopping until I get to my goal! Thanks for the insight!

So what Advocate hospital in the Chi-town area are you planning to go with? My doc is out of Good Sam in Downers.

 Oh nice! I've heard of that location as well, how did everything go there for you?? And I'm not sure as of yet I will know once I get the referral because they also have to confirm which surgeon takes my insurance so I could potentially out in the suburbs as well!

Okay, so my doc is Dr. Jeffrey Rosen and he is with Life Weigh Bariatrics and does surgery at Good Sam as does his associate, Dr. Allen Mikhail.

I am almost 13 years out RNY.