Insurance and bariatric surgery: How to navigate your benefits
After exploring your options and deciding that bariatric surgery is right for you, you’ll want to know how it will be paid for. Many insurance companies recognize the seriousness and health consequences of obesity and cover weight loss procedures — provided you meet plan-specific qualification criteria.
How to verify your own benefits
Although your surgeon’s office staff will verify your benefits as a complimentary service, it’s a good idea to contact your insurance company yourself to check into coverage and requirements. You can also read coverage documents provided to you by your employer and/or insurance company.
You’ll want to know if bariatric surgery is covered — if not, it’s likely listed in the plan’s exclusions under “obesity” or “weight loss surgery.” It’s very common to be quoted that bariatric surgery is covered if it’s medically necessary, but that’s only partially true because it must also be a covered benefit.
If you’ve confirmed that your plan covers bariatrics, you’ll then want to know what’s required. Each plan has a specific list of criteria and requirements that establishes medical necessity to the satisfaction of your insurance carrier. The most common place to find benefit criteria is simply in your carrier’s medical policy, but your employer may have an addendum document (“summary plan document/description”) that outlines additional or alternate criteria for certain services. A summary plan document often supersedes the criteria of the medical policy, so it’s important to know if an addendum like this applies.
Medical necessity vs. coverage exclusions
Although you may meet standard and widely-accepted criteria for medical necessity, your insurance is not required to cover bariatric surgery. If weight loss surgery services are listed as an exclusion, your insurance will not consider you for coverage, irrespective of your BMI and comorbid conditions. The denial rationale would not indicate that surgery isn’t medically necessary but rather that they simply do not provide this type of coverage, and unfortunately there is no appeals process for this.
Cash paying for surgery
If your insurance does not provide coverage for bariatric surgery, there are other options available to you. Depending on plan language, consultations, nutritional counseling and pre- and post-operative tests, labs and follow-up visits may be covered, although surgery is not. Verification of your benefits will help us outline potential costs to you at your consultation.
How to meet insurance criteria
Once your benefits have been confirmed, you’ll meet with a surgeon to consult. Your height, weight and BMI will be documented as well as comorbid conditions and tried and failed attempts at conservative, non-surgical weight management. If your plan requires a medically supervised weight loss program, you’ll start seeing a dietitian, typically on a monthly basis for the specified duration.
The most common insurance criteria is a psychological clearance, so you should plan to schedule an appointment with a mental health professional who will evaluate you to determine candidacy for bariatric surgery. It is important to rule out psychological disorders, disordered eating of any type, inability to provide informed consent or inability to comply with pre- and post-surgical recommendations.
Insurance authorization process
When all pre-surgical and insurance requirements have been met, the authorization process can begin. Your pertinent medical records will be gathered and submitted to your insurance company’s clinical review department. It can take up to four weeks to receive a determination, but two weeks is more customary. When we hear from your insurance, you’ll be notified of the approval or denial. If you’ve received an approval, surgery can be scheduled or confirmed.
If surgery is denied, we will review the decision and take the appropriate follow-up steps outlined by your insurance. Denials occur for a number of reasons, such as missing documentation or a lack of meeting of the minds about criteria that may be vague or open to interpretation.
Appeals
It’s important to thoroughly review denials because deadlines for appeals may be fast-approaching.
Typically, a peer-to-peer option is available as the first step of this process. A peer-to-peer is a scheduled discussion between your surgeon and the insurance company’s medical director to review the denial. When this conference is possible it’s very helpful because we’re able to get specific feedback from a reviewing authority about what else the insurance company is expecting us to submit or what they would like you to do to qualify. The denial may either be upheld or overturned at the time of this discussion, but usually it’s simply a tool for moving forward with the appeal.
If an appeal needs to be submitted, we will gather additional documentation that may have been initially omitted. If additional testing or office visits are required, these should be scheduled as soon as possible to ensure completion prior to the expiration of the appeal period.
There may be multiple possible levels of the appeals process. If need be, a second- or third-level appeal can be requested, with the final level usually being submission to an outside party for consideration. External review organizations are not affiliated with our office or your insurance company, so they review your clinical documentation from an unbiased standpoint.
What can I do to ensure approval?
Before your consultation, you’ll be given a patient health history questionnaire. It’s important to fill this out truthfully and completely because it will be translated into your medical record, which will be reviewed by the insurance company.
If you have any documentation (medical chart notes, personal records, logs or receipts) of your previous attempts at weight loss whether by diet, exercise or medical supervision, bring a copy to be reviewed and scanned into your chart.
If you’ve had a previous weight loss procedure, you should obtain copies of your operative report as well as pre- and post-op visits to demonstrate your committed follow-up and compliance with any recommendations that were made by your former provider.
The single most important thing that every patient should do to ensure the likelihood of approval by their insurance company is to remain in full compliance with the requirements set forth in the medical policy (or Summary Plan Document, if applicable). Medically supervised diets often must occur in consecutive months and should be spaced out by approximately 30 days. Failure to keep scheduled appointments in consecutive calendar months will often result in denial and may delay surgery or cause you to have to re-start the prescribed program from the beginning.
The MultiCare Center for Weight Loss & Wellness supports you before, during and after the weight loss journey.
