Obesity has reached a crisis level in this country, with obesity registering at 30 percent of the population. Gastric bypass surgery is generally considered to be the best surgical procedure for the treatment of morbid obesity. In fact, doctors are expected to perform 140,000 bariatric surgeries in 2005 alone.
As payers and practitioners in the medical community, we are well aware of these statistics and their impact on overall healthcare costs. And, until recently, not all insurance plans considered bariatric surgery as a medically necessary procedure. This is about to change. Federal healthcare authorities have changed obesity to be classified as an illness. This change often results in gastric bypass surgery being classified as a medical necessity for many overweight adults that meet the following criteria:
The patient’s body mass index (BMI) is over 40
The patient has failed one or more non-surgical, medically supervised weight loss programs
The patient has received a thorough psychological exam that confirms he or she is able and willing to conform to the dietary adjustments required by the surgery
Other medical conditions may also have to be considered; however, this change means you, as a payer, may be expected to provide coverage for cases that, in the past, would not have been covered.
At AllMed Healthcare Management, we understand the impact this change may have on your organization – both in terms of cost of services and in the volumes of cases that may require a second level of review. To help you with this process and to ensure you are able to administer claims in a timely and accurate manner, we have added five additional bariatric surgery specialists to our peer specialist panel. These specialists are available to help you ensure your claimants receive the care they need and are entitled to – while also making sure you’re not overpaying for services that may not be covered or are medically unnecessary.
As your Independent Review Organization (IRO), we make it our job to stay up-to-date on the latest medical advancements, medicalrulings, legal regulations and health insurance laws to ensure you receive medical advice and decisions that are based on defensible facts. It’s our commitment to ensure you receive the best service and outcomes.
