Question:
Is there a way to have surgery without my PCP's approval?

Hi.. My PCP is normally pretty cool and at first I thought she would be very supportive with my desire for surgery. I have been overweight since 9 years old (I'm now 31). I am 5'11" and weigh 278 pounds with a BMI of 38.8. I have High Cholesterol, borderline high blood pressure, and sleep apnea. She seemed very supportive until she asked about my diet history. She asked me the diets I've been on. I told her that I've been on alot of diets. Most times I lost about 20 pounds and then gained it back later. She asked me the names of the diets. I told her that they were one I made up myself (such as cutting out all junk food and limiting calories) and also working out at the gym. I guess they didn't count, since they weren't known diets like weightwatchers. She told me "You need to diet and exercise!" DUH...I've only tried that about a hundred times now... and from then on she didn't seem as eager to help me with getting surgery. I have United Healthcare (HMO) and called them and told them the situation. They seemed understanding and seemed to be willing to work with me without my PCP's approval. But don't I need a referral from my PCP to see a surgeon? What if my PCP won't refer me now? Am I stuck? I don't really want to change PCPs if I don't have to. Other than this situation, she's been a great doctor... can someone help me?    — Mike F. (posted on May 31, 2003)

May 31, 2003
Hi, I'm not sure about you're insurace company, but some companies have referral services where they, at the insurace company can make the referral to a doctor for you. I would call and check if this is the case with your company. You might also want to ask them if they can recommend a pcp doctor in your area who has referred patients to WLS surgeons before. Best of luck!!
   — Fixnmyself

May 31, 2003
If you have a PPO, you probably don't need a referral. I didn't. Of course, some surgeons require one. And if your insurance requires proof of previous diet attempts, you might have problems. You probably will need your medical records from your PCP to prove medical necessity (especially since your BMI is under 40) but you can request a copy of them. Good luck.
   — Patty_Butler

May 31, 2003
Check your Summary Plan Description or call your insurance company to see if you need a referral. Fortunately, many insurance companies are finding that having everyone get referrals from their PCP is a huge waste of time. Not many people go see, say, a cardiologist or a nuerologist unless they feel there is a legitimate reason. And while the whole idea behind having to have a referral was to make sure the PCP knows what the patient is doing, insurance companies now know this whole process really is time intensive for not only the MD office, but for the insurance company as well, including the claims payors, who have to make sure there was a referral before paying the claim. So, even HMOs are dropping the manidatory referral. The company I work for stopped requiring referrals January 2001, and we still get questions from members about it as well as referrals to specialists from our PCP offices!
   — koogy

May 31, 2003
I have UHC and can go to any doc for anything at any time without a referral. I mentioned to my pcp that I was thinking about wls and could tell he didn't think too much of it. When I got ready, I just called the surgeon of my choice and made an appt. My group has an internist on staff that they sent me to and he checked me out, took, my diet and medical history and ordered all my tests. Then my surgeon sent a letter of medical necessity to uhc. I had surgery in Feb and to this day my pcp does not know I had wls. he was left completely out of the loop. A lot of people assume that they need a referral when they don't. It depends on your insurance. Yours is the same as mine and BTW, I was approved in two weeks. Good luck!
   — Delores S.

May 31, 2003
I didn't need a referral, so I just started the process with my surgeon, with out ever seeing my PCP. I was a bit 'nervous' about going to my pre-op physical with my PCP when the time came but, he said that everything looked fine and that I would be glad I did it...and that was it. Do keep in mind though, that you will eventually have to face your PCP in the end.
   — eaamc

May 31, 2003
I did not need a referal to go for my first consultation with BTC. The problem I ran into is, BTC is 5 hours away from my home. And my surgeon wants me to have labs ran once a month when I am post-op. The only way for me to do that without having to drive 5 hours once a month, is for me to go to my PCP. So for me, I had to have my PCP's approval. Prior to me going to BTC I did not have a PCP. So I did a lot of asking, on this website, for help from people in San Antonio who know of a WLS friendly PCP. The one I choose is wonderful! I am so glad I was able to find a doctor who approves of my decission. In fact, he told me this will be one of the best things I have ever done for myself. Best of luck!
   — Maria S

May 31, 2003
Usually it's insurance that requires the referral, not the surgeon. Since your insurance doesn't require it, call around and make an appt or two.
   — [Deactivated Member]