Question:
My surgeon is not submitting me to the insurance company for approval!

My PCP appt was 8/30, QUIT SMOKING on 8/31 (since my surgeon will not perform surgery on active smokers), my surgical consult was 9/19, my psych eval was 9/27. I jumped thru all the required hoops, and everything that the surgeon needed was on his desk by 10/14 and reviewed. The psychiatrist has given the go-ahead for surgery. BUT......he indicated that [I quote from my copy of the conclusions to the report]: "There is no evidence of a psych disorder...or any contraindication to RNY...she does not have any evidence of unreasonable expectations or goals...she understands the risks and discomforts of surgery...she understand instructions and recommendations for before and after the surgery. Further, she is willing to comply...She appears to have accepted the need for active participation in the therapy process for life in order for her to succeeed...appears to be motivated...[OK, so far, so good]. "Having said that, it is important to remember that [the patient] has used food as a coping mechanism under stress in the past [Wow, an MO individual who uses food to cope? That's a first! ;o)]...Counseling should address her need to develop alternate ways of coping....should preferably begin before the actual surgery is performed." To continue: "In the past, [she] would invariably get discouraged when the degree of her weight loss was less than desired or not fast and consistent enough. She would then invariably lose motivation to continue with the program [<--another shocker! :O>]. Such lack of motivation needs to be addressed early on in psychotherapy before the gastric bypass surgery." So my surgeon has instructed me to begin therapy prior to surgery, which I'm totally in favor of. Let's face it--we wouldn't be MO if we didn't have food issues--although that's not the whole problem and we MOs know that. But here's the kicker: The surgeon's nurse told me that they will not submit my paperwork to the insurance company (BC/BS) until AFTER the therapy starts and (according to his nurse) "You've demonstrated that you're committed. We don't want you to think that this surgery is a quick fix. We don't want you to take this lightly." I asked in what timeframe would the paperwork be submitted (after the first session, after the third session, etc.) but was only told "you need to show us that you're committed." I have no problem with the psych recommendation, just the withholding of the paperwork. Doesn't the ins. approval process take several weeks to months? Isn't it reasonable to begin my therapy in this interim? And what if I'm denied? It doesn't seem prudent to initiate therapy to cope with the aftermath of a surgical procedure that I might not have. HAS THIS HAPPENED TO ANY OF YOU GUYS? It sounds as if my surgeon doesn't think that I respect him or have the integrity to follow his preoperative directive--that they have to (and I hate to use this word) blackmail me into beginning therapy. I know that he is a stickler with his preoperative requirements--and I've met all of them so far (including quitting smoking). He has been known to cancel on the morning of surgery because someone who "quit" smoking actually hasn't, or if the required preoperative nutritional or PT sessions are not done. So, if I were the type of person who said "ok" to initiate therapy and then didn't....Hey, he is the one who has the power to veto the surgery for any reason. What does this have to do with the INSURANCE approval? If any of his past patients have "stuck it to him" by not following his orders....then why should I be penalized? I don't think that I've given him the impression that I think this is a "quick fix" or that I would be noncompliant. Oh, wait---MO people are lazy, unmotivated, and shiftless, right? That must be the problem. Did I mention that I quit smoking? It'll be 2 MONTHS this Friday. I didn't fall over in a dead faint when he told me that one of the complications is death. Because I'm well aware of that. I didn't ask 400 questions because I had already researched the procedure extensively before I even called to make the appt. I'm also an RN who worked in ICU. He is aware of this. I know the complications that can happen to ANYONE having any surgery, particularly the MO. I'd appreciate it if anyone could offer any words of wisdom??    — Joyce C. (posted on October 22, 2002)

October 22, 2002
I agree. I would definately find another surgeon. Your surgeon (just as all physicians) should have to have a degree in compassion as well. Good Luck to you...
   — Marilayne M.

October 22, 2002
Find a new surgeon!!! You don't need another father, you need a professional surgeon who isn't into head games. What he and his office are doing is unconscionable. Good luck! PS, if you're in pittsburgh area, there are some great surgeons to choose from! Diana
   — dibie1221

October 22, 2002
whoops---thought you were from erie, pa---had you confused with someone else! Answer is same, tho---find a new surgeon ASAP!!!
   — dibie1221

October 22, 2002
I would recommend finding another surgeon as well. It sounds like your balanced and ready to go through this thing. You've certainly did your homework, I would suspect - by the time you get to the point you are now, you've researched and researched and researched. You've weighed out the odd's. You've gone through all your past history and you're ready to see this thing through, no matter what. Find a doctor (and there are plenty out there) who are equally as committed and understanding. I agree with one of the previous responses that referred to your city as Eerie, Indiana - that cracked me up...I agree though. Tis a sign, my sweet sister in spirit...tis a sign. Take heed and move on to one that fits you better. I changed three times before finding the surgeon that was just the right one for me. You will too ~ good blessings to you.
   — Lisa J.

October 22, 2002
My first thought is that the surgeon's office hasn't submitted paperwork yet because they know with a psych eval like that, the insurance company won't approve until therapy has begun and they are satisfied enough to approve you.<p>I kinda think the psych was drumming up for new business with that psych report though. The "lack of motivation" he put in the report all of us have gone thru with diets that didn't work on us. Who wouldn't lose interest in a diet where you starve yourself and lose .5 pounds per week? I think a different psychologist would've given you a more favorable report and none of this would be happening. Good luck to you!!
   — thumpiez

October 23, 2002
Joyce, first of all, congratulations on quitting smoking!!!!!! That is a giant step. The next thing is that I am always amazed by the psych reports that hold things up, my surgeon only wanted a psych report that told if i was mentally competent to make this decision or not! I also am a RN, and as you know many doctors, (esp surgeons) believe they rule the world. If you make the appointments to do the therapy and meet with him again, and he still doesn't think you are commited, I would consider another doctor, but first I would make sure it is him holding up the paper work, not someone in the office staff that likes to exercise their control. (We have read of that happening many times on this website)! What ever you outcome is, I wish you the best! God Bless you on this journey!<><
   — garnet156

October 23, 2002
Joyce, first of all congrats on quitting smoking and staying smoke free for 2 months. That alone takes alot of courage and with all the stress you are going thru, think of how strong you are (and committed) to stay smoke free. That committment alone will serve you well when you are post-op. Now, are you tied to this surgeon for any reason? Are there no others available in your area? There are surgeons that do not require a psych eval (mine didn't) and are not as stringent. The insurance process can take a few days to a few weeks or more. You can ask his office staff for your type of insurance what is the norm to wait. also if this surgeon has a support group, attend the group sessions. His other patients would have some insight for you. Good luck.
   — Cindy R.

October 23, 2002
Hi, everyone, it's ME, Joyce C, original poster. First of all, I just want to thank EVERYONE for their insightful and supportive responses!! This web is truly a Godsend! And, an UPDATE: I REALLY don't want to change surgeons; I have much respect for him despite the "ruling" and believe him to be vigilant, skilled, and conscientious, and "ooh, baby, that'sa what I like!" I don't want to sacrifice quality for "quantity". I spoke with the social worker who runs my surgeon's support group. She said that he was OBLIGATED professionally to insist on initiation of psychotherapy considering the report that he received. She also said that with my insurance (BC/BS - Traditional), I should get approval VERY soon once they submit, which is why it's being "held" for a bit. She was extremely supportive and informative. So thanks to her, and to all my AMOS family! BTW, I have contacted a counselor to start therapy ASAP. Thanks again, all, and if any other "interesting" things happen, I'll let you know!!
   — Joyce C.