Part of your decision to have bariatric surgery involves figuring out how you will pay for the procedure.
Insurance Coverage for Bariatric Surgery
While insurance coverage for weight loss surgery is widespread, it often requires a lengthy and complicated approval process. The best chance for obtaining approval for insurance coverage comes from working together with your surgeon and other experts.
Key Steps For Insurance Coverage
Here are some of the key steps you should take to obtain insurance coverage for weight loss surgery:
- Read and understand the "certificate of coverage" that your insurance company is required by law to give you. If you do not have one, consult your company's benefits administrator or ask your insurance company directly.
- You may be required to start with your primary care physician. In some cases, he or she is the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care physician.
- Before visiting the bariatric surgeon, organize your medical records, including your history of dieting efforts. They will be valuable documents to have at every stage of the approval process.
- Document every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight loss programs. Document "other" weight loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.
- If your surgeon recommends weight loss surgery, he or she will prepare a letter to obtain pre-authorization from your insurance company. The goal is to establish the "medical necessity" of weight loss surgery and gain approval for the procedure. The following information is generally included in the pre-authorization letter:
- Your height, weight and Body Mass Index and any documentation you might have as to how long you have been overweight.
- Simply describing your condition as "morbid obesity" is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken and documentation of the effects these conditions have had on your everyday life is necessary.
- A detailed description of the limitations your excess weight places on your daily activities, such as walking, tying shoes, or maintaining personal hygiene.
- A detailed history of the results of your dieting efforts, including medically and non-medically supervised programs, medical records and records kept of payments to and meetings attended with commercial weight loss programs.
- A history of exercise programs, including receipts for memberships in health clubs.
- Ask your doctor to include information from medical journals regarding the effectiveness of weight loss surgery, particularly information showing the control or elimination of obesity-related health conditions.
Thirty days is the standard time for an insurance provider to respond to your request. You should initiate a follow-up if you have not heard back in that time.
The Appeals Process
Even if your initial request for pre-authorization is not approved, you still have options available. Insurers provide an appeal process that allows you to address each specific reason they have given for denying your request. It is important that you reply quickly.
It is also recommended that, at this point, you enlist the help of an experienced insurance attorney or insurance advocate to properly navigate the complexities of the appeal process. Some insurers place limits on the number of appeals you may make, so it is important to be well prepared and that you clearly understand the appeal rules of your specific plan.
If your appeal for insurance coverage is denied, or if you don’t have insurance, there may still be other financial options available to you. Talk to your doctor about self-payment options such as payment plans that may help you pay for your procedure.
If you think you may be a candidate for weight loss surgery, talk to your primary care physician about Danbury Hospital, call 1-800-516-3657 for more information, or attend a free event and learn more about losing weight through bariatric surgery and if it’s right for you.