Help me get started....

I do not have a PCP since I have moved from one state to the other. I usually go to an urgent care. Where do I start for getting a letter of recommendation for approval of the surgery? Do I call the Dr. that I know who does the surgery? Can he make an appointment for me and make the recommendation to my insurance? My insurance has great coverage for this and a great approval record. I just feel so lost and like I will never get this done, or even head in the right direction.... please, someone, show me, or advise me on how to get this process done.

well for me, i had gone to a seminar I saw in the paper in Portland. If I hadn't of gone there I would probably never have had the surgery. It was by Dr. Stephen Tersigni of Coos Bay, Or., a veteran of over 700 WL surgeries. It sounded good so I went down for a consultation. Dr. Tersigni's office did all the contacting of the insurance co. for approval. All I did was sit and wait for Blue Cross to approve it, which they did after 6 weeks. I had to attend a class and one support group meeting, meet with a spychologist, and pre register at Bay Area Hospital in Coos Bay, all in 2 days. Surgery was scheduled and I went for it. I had the laparoscopic RNY and my experience at the hosp was all good. An excellent attentive staff. Went in on Tues and was out of hosp. Thurs morn. Lost 40 lbs in 6 weeks. I certainly wouldn't have been able to do this by myself if I had to do all the footwork. Jerry

Hi Jerry, Thank You. Now I know where to start. Did Dr. Tersigni need any other information? Like your past medical records or anything? I have medical records showing how many times I went on doctor recommended diets and failed. Of course, I dont remember how many times I tried prescription diet pills. Do you think I can contact the doctor and set up an appointment. I am down in Albany, south of Salem. Since I do not get the Portland Paper, any suggestions on how I can find out about up coming seminars?

Really don't know how often they are advertised. You can call his office for a consultation at 541 267 5151 ex 360 or 270. He will discuss everything in consultation that he did at the seminar. I didn't need any proof of diets, but meeting with the nice lady psychologist discussed that. I also had a few other factors like diabetes, knees giving me trouble, high blood pressure, and a little sleep apnea, although my weight was not that great, 270 lbs, which still put me in the obese catagory of at least 75 lbs over. I'm sure if you are a good candidate, they will do everything they can to get you approved. Jerry

Hi Christi, welcome to Oregon. I started with my PCP and he recommended and referred me to Dr. Emma Patterson in Portland. I would think you would need to start by getting a PCP, as you will probably need one, after the surgery if not before. My doctor is Bruce Thomson at Corvallis Family Medicine. He is, without a doubt, the best, kindest, most knowledgeable, helpful WAY above and beyond the call of duty doctor I have ever known. There is also a doctor in Corvallis at Good Samaritan Hospital (Dr. Read) who does bariatric surgery. I don't know too much about him. My insurance had to have a recommendation and referral from my PCP. You might need to find out what your insurance requires. Hope this helps. Please feel free to e-mail me any time. If you want to call, I'm in the phone book. Kathy McNurlin - Monroe area. Oh, I forgot! I think my surgery will be in October. Kath

I went with the one with the most experience, best reputation, and no fatalities. Basically, the best candidate for the job. And I wasn't disappointed.

Christi, The fact that you have been on this site, know something about your insurance coverage pertaining to this surgery, and have decided that you are interested in seeing if you can make it happen, means that you have already made good progress in the process. It's never an overnight decision (as it shouldn't be) and getting your head around the idea is the first step. I would call and talk to your insurance company first. Ask what their criteria is for getting approval for by-pass surgery. Get the specifics as far as what documentation will be required. In the mean time collect copies of any past medical treatment you have had for any of the related co-morbidities. Those would include diabetes, high blood pressure, joint problems, etc. The medical world keeps records for everything, and places like Kaiser and/or urgent care centers have a department just for retrieving record requests. It usually involves some kind of written request from you, but you can find out a lot on the phone as to what they need from you. It is always a good idea to hook up with a PCP. My insurance doesn't require I get referrals from my PCP to see specialists, but in the case of this surgery they did require a letter from my PCP recommending the surgery. My doctor had to re-write it because insurance had very specific wording they needed to see in the letter. I had only been with my PCP for a couple of months when I asked this of her - so don't think that by not having had one for a while that you won't be able to get a doctor to back you up on needing/wanting the surgery. There are some tests that the weight loss surgeon will require before they submit for approval to your insurance, but often they can/will order those tests and direct you the appropriate doctors once you are in their program. I agree that attending a seminar by one of the WLS doctors is probably the best way to begin. The Oregon Clinic in Portland (Drs. Patterson and Hong) has a great informative seminar. To find out when the next one is and get on the list to attend call their office. Also OHSU, Kaiser and the above mentioned doctor all have information seminars. They usually bring their team with them that answers questions about navigating the insurance approval process. Make 411 your friend - for getting phone numbers of records, hospitals, doctors, etc. You can usually track down just about anything on the phone - you just talk regular people working their regular work day into helping you. That strategy worked well for me when it came to the huge approval department in my insurances headquarters. Always find out if you can fax something, when a hard copy is following in the mail. That one saved me about three weeks on my approval process. The day I got approved for surgery the hard copy had just arrived after snaking its way through the mail sorting room for three weeks. I called a lot "just checking the progress of my approval". You need to be a squeeky wheel with out ******g someone off. Though it may take a long time to get a surgery date - where will you be in that same amount of time if you aren't doing the work towards getting approved? All of the sudden one day you say "thank goodness I started this when I did". Now when I look back it seems like it all went so fast, but I will never forget how desperate I was for it to happen month after month. It took lots of small steps and many big steps, but it added up eventually to a surgery date. The great thing is you are starting with an idea that your insurance company at least historically has paid for this procedure. Good luck to you! Patty

Thank You, although I was extremely devastated the other day. I finally got in touch with the bariatric program that is here, and the receptionist advised me to contact my insurance regarding coverage. So when I did that, my insurance said that was excluded from our plan. I was so upset and thought this would never happen for me. I got myself pulled together a few hours later.... and decided that even though the operator I spoke with at my insurance said what she said, I decided that I will still go for it. I will fill out all my forms and go to my seminar in October. My thoughts are that when the doctor submits the letter of recommendation, hopefully that will persuade the insurance to cover this. If not, I will just appeal the decision and try and keep moving forward. My insurance is Cigna PPO and so far from what I have read about them thru this site is that they have a good approval rate. SO I was thinking that the operator said that because she more or less had to. I do have a PCP out of state and I am sure she would gladly make the recommendation. She has been my PCP since I was about 15. I did get my Bariatric program paper work today and I plan on getting all my medical records mailed to me. I know without a doubt that I qualify and I think once my insurance gets the letters and facts behind the recommendation, they will make the approval. After all, the long term medical care they will have to provide vs this will hopefully convince them. In the mean time, I have bought myself a bowflex and began to change my eating habits and what I am eating. Trying to ready myself for a life time of better eating and the discipline of working out and dedicating the rest of my life to a healthier and happier person.

Christie. I work in the insuranace field and Legacy who has the Oregon Clinic, Obesity Institute. You should contact your insurance and find out who your network providers are and I'm sure it will be with the Providence Facilities. I have no idea of what kind of clinics they have for this surgery. I do know that Legacy has the Obesity Institute They will want you to attend a seminar first and you will need to sign up in advance for that. Since they are a Institue for Obesity only, they can give you all the information that you will need to pursue this with your insurance. I believe they also have PCP's that they can refer you to get a referral if needed. I have seen Cigna approve this surgery but I know that they make you jump thru a lot of hoops! So be prepared for a challange. Do not get discouraged. The clinic is wonderful in helping you work this out with your insurance. Dr Hong and Dr Patterson and Dr Jan are all really great. Dr Patterson is one of the leading Gastric Surgeons. I had Dr Hong and he is also really great. They have all the specialist right in the clinic, diatician, physical therapist, psycologist, Nurse practitioner, and the surgeons. I know that it will be a distance for you but I think you will be happy with the support and help that you will recieve from the Institute.