IRO Bariatric Medical Reviews - IRO Medical Review Criteria for Bariatric Surgery

Released on = October 22, 2004, 11:39 am

Press Release Author = Debbie Caldwell

Industry = Healthcare

Press Release Summary = Trimming the Fat on Healthcare Costs: IRO Medical Reviews
Help Ensure Medical Necessity of Bariatric Surgery.

Press Release Body = Losing weight is the #1 New Year’s resolution in America.
However, many people believe they are so overweight that bariatric surgery may be
the only option. And they may be right. During the past 20 years, there has been a
dramatic increase in obesity in the U.S. Currently, more than 44 million Americans
are considered obese. In 1995, just 20,000 weight-loss operations were performed.
Last year, physicians performed 103,000 bariatric surgeries, with more than 144,000
bariatric surgeries projected in 2004.

For insurance companies, bariatric surgery numbers are alarming. Bariatric surgeries
average $30,000 each and sometimes more. And now Medicare has changed obesity to be classified as an illness. This change often results in gastric bypass surgery being classified as medically necessary and means health insurance companies may be expected to pay for claims that, in the past, would not have been covered.

To ensure the medical necessity of the procedure, many insurance companies are
turning to independent review organizations (IROs) for bariatric medical reviews.
Independent Review Organizations (IROs) offer arms-length medical reviews of
difficult or questionable bariatric cases and help insurance companies determine
whether or not the bariatric procedures are medically necessary. These medical
reviews are done by a panel of like specialists, or physician peers, and are based
on proven medical facts.

“Health insurance payers really do care for their customers and want them to get the
treatments they need to maintain a healthy lifestyle,” said Dr. Skip Freedman,
medical director at AllMed Healthcare Management, a leading Independent Medical
Review (IRO) Organization. “Our role is to help payers make sure they aren’t paying
for procedures that are not needed or might have better results with less expensive
treatments.”

According to Dr. Freedman, the main questions that need to be asked in a medical
review to determine whether bariatric surgery is truly required include:

•Is the person suffering from morbid obesity (BMI over 40)?
•Has the patient passed/failed one or more non-surgical, medically supervised weight
loss programs?
•Does the patient have a medical illness related to obesity?
•Is the patient willing to participate in a pre-surgery weight loss effort?
•Can the patient make the lifestyle adjustment necessary to sustain weight loss?

Only by answering these questions in a medical review can one determine whether a
claim is medically necessary or simply a cosmetic, optional procedure. More
information on bariatric surgery and IROs can be found on AllMed’s Web site at
http://www.allmedmd.com.

About AllMed:
Allmed reviews claims for issues of medical necessity, standard of care,
experimental / investigational, hospital quality management, code unbundling, fraud,
and other issues that affect healthcare decision-making.

AllMed has trained review specialists in the following specialties: Acupuncture
Allergy/Immunology, Anesthesiology, Audiology, Bone Marrow Transplantation,
Cardiology, Cardiovascular & Thoracic Surgery, Chiropractic, Dentistry, Dermatology
/ Dermatopathology, Diagnostic Radiology, Emergency Medicine, Endocrinology,
Forensic Medicine, Gastroenterology, General Surgery, General, Vascular & Thoracic
Surgery, Hand Surgery, Hematology/Oncology, Heart Transplant, Infectious Diseases,
Internal Medicine, Kidney Transplant, Liver Pancreas Transplant, Neonatology,
Nephrology, Neurological Surgery, Neurology, Obstetrics/Gynecology, Ophthalmology,
Oral & Maxillofacial Surgery, Organ Transplant, Orthopedic Surgery,
Orthotics/Prosthetics, Otolaryngology, Pain Management, Pediatric Cardiology,
Pediatric Endocrinology, Pediatric Gastroenterology, Pediatric Nephrology, Pediatric
Neurology, Pediatric Ophthalmology, Pediatrics, Pediatric Surgery, Physical Medicine
& Rehabilitation, Physical Therapy, Plastic Surgery, Podiatry, Prosthodontics,
Psychiatry, Psychology, Pulmonary Medicine, Radiation Oncology, Radiology, Rheumatology, Sleep Disorders, Speech & Language Pathology, Toxicology, Transplant Surgery and Urology.

Web Site = http://www.allmedmd.com

Contact Details = Debbie Caldwell
aha!pr, inc.
http://www.allmedmd.com
503-297-1116
debbiec@aha-pr.com