Who's Driving The Bus?  Providers or Payers?

Who’s Driving The Bus? Providers or Payers?

Imagine this scene:   Your body mass index is well above 40, you have several obesity-related diseases and you’ve tried and failed numerous diets over many years.  YOU ARE FINALLY READY to consider bariatric surgery.  You medically qualify for bariatric surgery and you are committed to making the changes necessary to make it succeed.  Your primary care doctor is very supportive.  Now what?

You go to a patient seminar for a respected bariatric “center of excellence” and get very excited about your surgical options – – you have a tool within reach that will help you meet your goal of achieving better health.  At the seminar you sign a couple forms, they copy your insurance card and you get an exciting phone call that your insurance covers surgery!  YAY, right?

You invest several hundred, maybe even over a thousand dollars going through the process your program requires:

  • You pay for and complete a six-month diet [even though it’s not supported by evidence-based medicine]
  • You pay for a sleep study because it wasn’t covered by insurance
  • You pay a substantial share of the psychological evaluation because not much of it was covered by your insurance because the provider was out of network
  • You pay your co-payment for the nutritional evaluation performed by a dietician
  • You pay out of pocket for a physical therapy evaluation

But then you get the exciting news that you PASSED the program and they are ready to submit to your insurance!  YAY, right?

Now imagine getting a call from the program’s “patient advocate” telling you they won’t submit a request for authorization to your insurance company because you don’t meet the insurance plan criteria.  She tells you they won’t submit it because it would be denied.  Sadder still is that she tells you this in a way that doesn’t hide her total indifference to how DEVASTATING this is to you:

“They require you to have a BMI over 40 for the last 5 years and your BMI was 38.4 in 2009 according to your chart. You wouldn’t be approved.”

“But that was when my doctor put me on Phentermine . . . I lost weight but my blood pressure shot up so he took me off it and I gained it right back!”

“I’m sorry but that’s what your insurance company says. There’s nothing I can do.”

“But what about my surgery? What about all the money I’ve spent getting ready? I planned time off from work. My sister is coming to help me with my kids while I recover. What am I supposed to do now?”

“I’m sorry.”

But you could tell she wasn’t sorry.  She was busy.  She was done with you.  Maybe she was “advocating” for someone else.  Maybe she even showed that someone else a bit more compassion than she showed you.

I wish I could tell you this was a dark fairy tale.  I wish I could tell you this never happens.  Sadly it is too real.

We heard versions of this story twice in the past week and a half from opposite parts of the country, prompting me to write this.  We hear versions of this story all the time, usually when that patient rejected by their provider wants our help to appeal this “denial.”  Imagine how frustrating for us to tell them that in this case the “bad guys” aren’t your insurance plan – – – at least not quite yet.

We work with compassionate bariatric providers every day, some of whom will read this and not believe this is a real story.  “This would never happen in our program.”  While I hope you’re right we’ve seen these rejections sometimes happen without the surgeon or program director having any idea their own staff is sabotaging their practice by limiting the number of cases.  They don’t know their judgment has been usurped by the “criteria” of insurance plans and payers.  Wrong-Way-Sign

This rejection isn’t a denial you can appeal to the insurance company – they haven’t done anything wrong – at least not quite yet.  In many ways this rejection is much, much worse because it prevents that patient from starting a fight against the insurance company.  It prevents that patient from exercising their RIGHT to appeal any denial, a right all patients possess regardless of what elements of the payer criteria are not satisfied.  It is absolutely the wrong way to handle things.

Why would a bariatric provider not want to give that patient a chance to fight?  That question doesn’t have an answer which satisfies me.  It’s not a fight they have to spend time or effort on – all they have to do is submit the information they’ve got and get the payer’s answer.  Even if that answer is a resounding “NO” it is an answer the patient can appeal.  The provider stands to benefit greatly if that denial is overturned.  But to refuse to allow the patient that chance????  Instead they blandly say “I’m sorry” when they really mean “I can’t be bothered.”  It stupefies me.

Insurers Drive The Bus I’m still naïve enough to believe that doctors and their integrated health care professional team should make decisions as to what is “medically necessary” and what treatment options should be explored with their patient.  I still believe health care providers should be the ones “driving the bus” – the ones calling the shots with regard to what is or is not “medically necessary.”  Certainly there are passionate providers and programs that truly do everything they can to help their patients get in the game and fight to get insurance coverage for the treatment which is right for them.  We applaud them and love helping those patients.

We hear from many sources across the country that numbers of bariatric surgery cases are on the decline across the board.  We hear it from providers, most of whom are performing fewer surgeries.  We hear from industry representatives who confirm their accounts aren’t as busy.  We hear it from medical societies and others supposedly “in the know.”  So if that’s true, and I know that it is, my bariatric surgery insurance tip of the day is to remember that a patient who needs bariatric surgery is NOT your enemy!  They are not a disposable item who can be tossed away because their insurance is “too hard.”  They are a person who needs, wants and deserves a provider willing to help them.  They need someone who will get them in the game; not sit them on the bench.  They need someone who is not going to hand the keys over to the insurance industry to make decisions about whether they should get access to care.
They need someone willing to DRIVE THE BUS.


  1. Dirk RodriguezDirk Rodriguez05-01-2013

    Excellent piece…..Keep banging at the door Walter, it is always a pleasure to hear /read you.
    As you stated years ago, obesity is still the last acceptable bastion of discrimination.

  2. Walter LindstromWalter Lindstrom04-10-2013

    Thank you, Mary! Appreciate the kudos.

  3. Mary EllistonMary Elliston04-10-2013

    You hit the nail right on!! I am a bariatric coordinator and work primarily with preauthorization for bariatric surgeries. We must fight! In our practice the patient and I are a team. When we run into the above situation, we come up with other solutions to document that history. I know on the other end is someone just checking off boxes of that plan’s requirement. If we can give them something to check off, it usually sails right through. Sadly we do get patients that come in, that have been traumatized by this kind of thing. Keep speaking out Walter!! You are doing the cause a lot of good.

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