Insurance and bariatric surgery: How to navigate your benefits – MultiCare Vitals
After exploring your options and deciding that bariatric surgery is right for you, you’ll want to know how it will pay for itself. Many insurance companies recognize the seriousness and health consequences of obesity and cover weight loss procedures, as long as you meet the plan’s specific qualifying criteria.
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how to check your own benefits
Although your surgeon’s office staff will verify your benefits as a free service, it’s a good idea to contact your insurance company yourself to verify coverage and requirements. You can also read the coverage documents provided by your employer and/or insurance company.
Reading: Why don’t insurance companies cover bariatric surgery
You’ll want to know if bariatric surgery is covered; otherwise, it’s likely listed in the plan’s exclusions under “obesity” or “weight-loss surgery.” It’s very common for bariatric surgery to be cited as 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 bariatric surgery, then you’ll want to know what’s required. each plan has a specific list of criteria and requirements that establish medical necessity to the satisfaction of your insurance company. The most common place to find benefit criteria is simply in your insurer’s medical policy, but your employer may have an additional document (“Summary Plan Document/Description”) that describes additional or alternative criteria for certain services. A summary plan document often supersedes medical policy criteria, so it’s important to know if a rider like this applies.
medical necessity versus coverage exclusions
Although you may meet the 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, regardless of your body mass index and comorbid conditions. the justification for the denial would not indicate that the surgery is not medically necessary, but rather that they simply do not provide this type of coverage and, unfortunately, there is no appeal process for this.
cash payment for surgery
If your insurance doesn’t cover bariatric surgery, there are other options available to you. Depending on the language of the plan, consultations, nutritional counseling and pre- and post-operative tests, laboratory tests and follow-up visits may be covered, but not surgery. verifying your benefits will help us outline potential costs to you at your consultation.
how to meet insurance criteria
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Once your benefits have been confirmed, you will meet with a surgeon to consult. Your height, weight, and body mass index will be documented, as well as comorbid conditions and tried and failed attempts at conservative, non-surgical weight management. If your plan calls for a medically supervised weight loss program, you’ll begin seeing a dietitian, usually once a month for the specified duration.
The most common insurance criteria is a psychological clearance, so you should make an appointment with a mental health professional who will evaluate you to determine if you are a candidate for bariatric surgery. it is important to rule out psychological disorders, eating disorders of any kind, inability to give 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 relevant medical records will be collected and forwarded to your insurance company’s clinical review department. it can take up to four weeks to receive a determination, but two weeks is more common. When we hear from your insurance, you will be notified of the approval or denial. if you have received an approval, the surgery can be scheduled or confirmed.
If surgery is denied, we will review the decision and take appropriate follow-up action as outlined by your insurance. denials occur for a number of reasons, such as lack of documentation or disagreement of opinion on criteria that may be vague or open to interpretation.
It is important to review denials carefully because the deadlines for appeals may be fast approaching.
Typically, a peer-to-peer option is available as the first step in this process. A peer-to-peer discussion is a scheduled conversation between your surgeon and the insurance company’s medical director to review the denial. when this conference is possible, it is very helpful because we can get specific feedback from a review authority on what else the insurance company expects us to submit or what they would like me to do to qualify. the denial can be upheld or reversed at the time of this discussion, but is usually simply a tool to move forward with the appeal.
If an appeal needs to be filed, we will collect additional documentation that may have been missed initially. if additional tests or office visits are required, they should be scheduled as soon as possible to ensure they are completed before the appeal period expires.
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There may be several possible levels of the appeals process. if necessary, a second or third level appeal can be requested, with the last level usually being submitted to an external party for consideration. External Review Organizations are not affiliated with our office or your insurance company, so they review your clinical records from an unbiased standpoint.
What can I do to ensure approval?
Prior to your consultation, you will be given a questionnaire regarding the patient’s health history. it is important to fill it out truthfully and completely because it will result in your medical record, which will be reviewed by the insurance company.
If you have any documentation (medical chart notes, personal records, records or receipts) of your previous attempts to lose weight, whether through diet, exercise or medical supervision, please bring a copy for them to review and scan into your chart clinic.
If you have had a previous weight loss procedure, you should obtain copies of your operative report as well as pre- and post-operative visits to demonstrate your commitment to follow through and adhere to the recommendations made by your previous provider.
The most important thing any patient must do to ensure the likelihood of approval by their insurance company is to fully comply with the requirements set forth in the medical policy (or summary plan document, if applicable). medically supervised diets often need to be done in consecutive months and should be spaced about 30 days apart. failure to keep scheduled appointments in consecutive calendar months will often result in denial and may delay surgery or cause you to have to restart the prescribed schedule from the beginning.
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