Insurance Requirements for Weight Loss Surgery in West Palm Beach

Insurance coverage is a big concern of most patients. A growing number of states have passed laws that require insurance companies to provide benefits for weight loss surgery for patients that meet the National Institute of Health surgical criteria. Most insurance companies require a lengthy approval process. Your best chance for obtaining approval for insurance coverage comes from working as a team with your bariatric surgeon and other experts to whom you are referred. Here is some basic information about how insurance companies function. Obtaining this information will facilitate more success in the approval process. First, we recommend you read the three points outlined below before making your first office visit.

  1. Always check with your insurance company and find out if your specific policy covers weight loss/bariatric surgery. Although medical insurance companies in certain states such as Virginia, Maryland and the District of Columbia are now required by law to offer obesity surgery coverage, not every policy that they offer has to. There is often the opportunity to upgrade your policy to one that does cover obesity surgery. If for some reason you cannot, your remaining options are to change your insurance company or self pay.
  2. We ask that you take the responsibility to check with your insurance company, not with the doctors office, if the surgeon is an in-network provider, an out of-network provider, a preferred provider or non-participating provider. This will determine how much you will be required to pay. Often times an insurance company will reimburse at a lesser percentage of the billed amount, and make the insured responsible for the difference when care is provided by an out of-network provider or a non-preferred provider. If a specialist you have been referred to is not available within the network, and there is medical necessity for the referral, the insurance then will usually treat the specialist as an in-network provider.
  3. Please check with your insurance company if you need a referral to see a specialist or an out of-network provider. If a referral is not obtained, you will be responsible for all related charges, and we will not be able to obtain pre-certification for obesity surgery.

Once your weight management surgery team determines if you qualify for obesity surgery based on the 1991 NIH Consensus Conference criteria, and your pre-operative medical work-up is completed the usual next step is to obtain pre-certification from your insurance company for the surgery. This can be challenging. Here are some tips to help facilitate your success:

  1. Begin obtaining pertinent medical records which document any co-morbid conditions you have such as high blood pressure (HTN), diabetes, sleep apnea, urinary stress incontinence, degenerative weight bearing joint disease, GERD, heart disease, and other obesity co-morbidities. Obtaining dieting/nutrition records is as imperative as obtaining your medical history records. Medically-supervised dieting programs or dieting medications prescribed by physicians should be documented as much as possible. Lately this has been the most common reason why obesity surgery pre-certifications have been denied. Document to the best of your ability your dieting history. Help provide your surgeons office with the necessary information for them to be able to submit a strong pre-authorization letter. It will be your job as the patient to obtain that information.
  2. Do not ignore commercial weight loss efforts such as Weight Watchers, Jenny Craig, etc. Although these records can be difficult to obtain, these records are sometimes used as substitute for the required ‘medically supervised’ diets that an increasing number of insurers routinely require.
  3. Once all your information has been collected and your medical workup completed, the doctor will write a pre-authorization letter to your insurance company documenting medical necessity based on your medical history, and dieting history records. To minimize the inevitable ‘but we never got your request’ from the insurer, we mail the requests by tracked mail or fax.
  4. Do not be hesitant to approach other patients at seminars or enter chat rooms on the web. They are important resources for gathering important information about your insurance company than from people who have ‘been there, done that’. Although our office has acquired a good amount of experience over the last few years with insurance companies and obesity surgery claims we continue to learn more every day. Help our office help you.
  5. Patients should take responsibility under the guidance and direction of your surgeon’s office for doing the follow-up on the preauthorization submission. You must actively participate in your healthcare and that means contacting the insurance company to get a response or to provide answers to questions or give more information.
  6. Be careful with appeals and grievances. A ‘no’ response may just require additional information. Before you proceed with an appeal consult your coverage booklet or certificate of coverage and know your rights. There often is a limit to the number of appeals you can submit as well as a limited time frame. Prior to proceeding with one obtain the reason for the rejection (preferably on paper) and what specifically the insurance wants as proof of documentation. Then do not proceed until you are sure you have all the necessary information and you have consulted with your physician.
  7. We like to get approval the first time! Each insurance company has individual procedures for approval.
  8. You must be assertive in the approval process. Although, we will provide all the necessary information and call the companies when needed, you play an important part in this process. Call the insurance company and have them assign you a customer service representative that will follow you through this whole process. Many people give up too soon. Persistence is key.
  9. Know your insurance company and get it in writing when you receive important information. The following information is generally included in the pre-authorization letter:
    1. Your height, weight and Body Mass Index (BMI) and any documentation you might have as to how long you have been overweight
    2. Just defining your condition as ‘morbid obesity’ is not adequate. A complete summary of all your obesity-related health conditions, which include records of treatment, a history of medications taken and documentation of the effects these conditions have had on your day-to-day life is needed.
    3. A detailed description of the limitations your excess weight places on your daily activities, such as walking, tying shoes, or maintaining personal hygiene.
    4. A comprehensive history of your dieting trials, including medically and non-medically supervised programs, medical records and records kept of payments to and meetings attended with commercial weight loss programs.
    5. A detailed description of exercise programs, including receipts for memberships in health clubs.
    6. A personal letter from the patient addressing all of the adverse ways that obesity impacts your life will be helpful. Include information on you personal, professional, social and intimate life. For example, how do you feel when you fly on an airplane or go to the movies. What about a water slide? Do you feel uncomfortable with public speaking? Are you in a healthy intimate relationship with your significant other? This helps personalize your case.
To schedule a consultation, contact us today 561-627-4107