IRO Bariatric Medical Reviews - IRO Medical Review Criteria for Bariatric Surgery
Trimming the Fat on Healthcare Costs: IRO Medical Reviews Help Ensure Medical Necessity of Bariatric Surgery.
Portand, OR (PRWEB) October 18, 2004 -- 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.
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Source : http://www.prweb.com/releases/2004/10/prweb168261.htm