Center of Excellence A Bariatric Surgery Center of Excellence is a bariatric program that has been designated a Bariatric Surgery Center of Excellence (COE) by the Surgical Review Corporation, a nonprofit corporation that: – Establishes guidelines for assessing bariatric programs – Evaluates bariatric programs to ensure they meet certain standards for recognition as a COE A bariatric program that has been designated a COE has met strict criteria and delivers bariatric care that meets high standards.
Certificate of Coverage A document provided by a health insurance company that describes the details of the plan’s policy, including requirements for eligibility, benefits, deductibles, maximums, and exclusions of coverage.
Dumping Syndrome An uncomfortable episode of nausea, lightheadedness, upset stomach, vomiting, and/or diarrhea, related to ingestion of high-sugar, high-fat foods or liquids that can occur after certain bariatric surgeries, such as gastric bypass.
Fully Insured Plan A type of health insurance plan in which the employer pays a monthly premium for a standardized health plan from an insurance company that assumes all risk and cost involved. The insurance company generally makes coverage decisions and must abide by state and federal regulations.
Gastric Banding Surgery This is a restrictive surgical procedure during which a silicone band is placed around the stomach, creating a small pouch. The band includes a balloon that is filled with a nontoxic fluid, most commonly a saline solution; adjustments are performed by a healthcare professional who accesses the balloon via a subcutaneous port.
Gastric Bypass Surgery This surgical procedure uses both malabsorption and restriction. During gastric bypass, the operating surgeon uses part of the stomach to form a small stomach pouch and reroutes a part of the small intestine. There are several variations of gastric bypass surgery including Roux-en-Y gastric bypass, extensive gastric bypass, and very long-limb gastric bypass.
Morbid Obesity A Body Mass Index of 40 or greater, which is roughly equal to 100 pounds or more over ideal body weight, or a Body Mass Index of 35 or greater with one or more co-morbid condition; these weight levels can be life-threatening.
Multidisciplinary Bariatric Program A team approach to testing and treatment of clinically severe obesity. It includes surgical, internal medicine, nutrition, psychiatric, exercise physiology, assessment, and treatment.
NIH Surgical Criteria The National Institutes of Health has established minimum requirements for deciding whether bariatric surgery is the right treatment option: – 100 pounds or more above ideal body weight or a BMI of 40 or greater1 – BMI of 35 or greater with one or more obesity-related health condition1
Self-Funded Plan A type of health insurance plan in which the employer assumes all risks and costs in providing healthcare to employees and, therefore, decides what is and what is not covered, such as bariatric surgery. Self-funded plans are usually administered by an insurance company. This insurance company is often referred to as the third-party administrator (TPA) of the plan. The TPA performs administrative functions only and does not determine coverage. Self-funded plans are exempt from state regulations, including mandated benefits, premium taxes, and consumer protection laws, but they must meet federal regulations.
Summary Plan Description Employers with self-funded health insurance plans are legally required to provide this document to their beneficiaries. The document provides plan participants with important information about their health benefits. This includes plan rules, financial information, and information on the operation and management of the plan. The information contained in the Summary Plan Description is similar to what is found in the Certificate of Coverage provided by a health insurance company.
The Surgeons’ Group, P.C.
Dr. John L. Mathews
D.M.D., M.D., F.A.C.S.
Diplomate, American Board of Surgery