Insurance and Bariatric Surgery

Once people decide to have bariatric surgery, one of their first concerns is how to pay for it. If you have health insurance, begin by learning as much as you can about the benefits your policy provides, and then follow the company’s qualification process to the letter.

More Insurance Companies Offering Bariatric Surgery Benefits

Most states have passed legislation that requires health insurance companies to provide weight loss surgery benefits for obese people who meet the National Institutes of Health (NIH) criteria for this procedure. However, the amount of reimbursement people receive varies widely, and the approval process tends to be detailed and lengthy. Furthermore, despite legislation, some insurance policies specifically exclude obesity treatment or have such strict criteria for bariatric surgery that many people fail to qualify.

A 2004 survey of employer-sponsored health insurance program benefits found that only 50% of insurance programs offer weight loss surgery benefits and that most programs required people to prove they have made a significant effort to lose weight using other medically supervised methods.

Tips for Getting Insurance Coverage

The following tips can improve your chances of getting your insurance company to approve your request for weight loss surgery benefits:

Read and understand your insurance company’s certificate of coverage.

The first step you need to take is to read and understand your insurance company’s “certificate of coverage.” You can get a copy of this document from your employer’s human resource department, or you can request a copy directly from your insurance company.

Ask your insurance company for a list of approved bariatric surgeons.

Some insurance companies will only reimburse the costs of surgery if the procedure is performed by an approved bariatric surgeon or at an approved facility. Be sure you investigate this issue before making an appointment with a surgeon.

Get a referral to a qualified bariatric surgeon.

Once you understand the type of coverage available from your insurance company, contact your primary care physician and ask for a referral to a qualified bariatric surgeon who accepts your insurance program.

Keep detailed records of conversations with your insurance company.

Document every conversation you have with your insurance company’s representatives regarding weight loss therapies. Ask for the employee’s name or employee ID and jot down this information along with the date and time of the call and a brief synopsis of the information the insurance company employee gave you. This will help you remember exactly what they require from you to meet eligibility and this information may come in handy if they later try to reverse their claim.

As of February 2006, Medicare has provided benefits for open and closed (laparoscopic) weight loss surgeries. However, the procedures must be performed at a facility that has earned the Surgical Review Corporation Center of Excellence designation.

Document all weight-related expenses.

Provide details and receipts for every visit you made to healthcare professionals for treatment of obesity or obesity-related health issues within the past few years. Also provide receipts for any commercial weight loss programs, diet centers, and/or fitness clubs you have joined.

Work with your primary care physician and bariatric surgeon on the insurance authorization process.

After a qualified bariatric surgeon agrees that you are a candidate for bariatric surgery, he or she will begin the insurance authorization process. The surgeon will contact your primary care physician and ask that he or she provide written documentation that weight loss surgery is medically necessary for your health.

Your primary care physician must provide documentation verifying that you:

• Are morbidly obese with a BMI of 40 or greater, or that you have a BMI of between 35-39.9 and potentially life-threatening, weight-related health problems like diabetes, sleep apnea, high blood pressure or heart disease.
• Have been seriously overweight for at least 5 years.
• Have attempted medically supervised weight loss therapies such as weight loss medications, behavioral support groups like Overeaters Anonymous, or medically monitored weight loss programs like OPTIFAST^® or Medifast^® for at least 2 years without success.
• Have no history of substance abuse, including alcoholism.
• Have had a thyroid test, and that the results will be supplied to the surgeon.

The letter should also indicate if you have serious kidney, liver, or gastrointestinal disease.

What if your request for coverage is denied?

Insurance companies are required to allow people to appeal the company’s coverage rulings. The trick is to understand the reasons you were turned down then appeal the decision quickly by providing documentation that address the insurance company’s specific concerns. Often, your bariatric surgeon’s office personnel can advise you regarding the appeal process.

What if the appeal is denied too?

If you still want to go ahead with weight loss surgery, there are several payment plan options you should investigate:

• Investigate medical loans through local banks or online via Bank of America or E-Loan websites. However, with the recent tightening in the credit market, these loans have become more difficult to obtain.
• Ask if your bariatric surgeon offers a payment plan. Many of them do.
• Look for a low-interest credit card through a credit union.
• Determine if you can pay some of the costs by saving before-tax dollars in a Health Savings Account.
• Consider lap band surgery. It tends to be less costly than bypass techniques like the Roux-en-Y, and it results in fewer complications which can also help keep the costs down.