Insurance Requirements for Weight Loss Surgery

Insurance coverage is a big concern for most patients. The first visit is usually covered by your insurance plan, even if they do not cover bariatric surgery. At your first visit we will determine if your insurance plan has bariatric coverage. More and more insurance companies are dropping bariatric coverage to reduce costs. Most insurance companies require a lengthy approval process. Your best chance for obtaining approval for insurance coverage comes from working as a team with our office insurance specialists. To understand the insurance approval process please read the points outlined below:

1. Check with your insurance company and find out if your specific policy covers weight loss/bariatric surgery. 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 check with your insurance company if we are an in-network provider for your plan. You should also determine if you have out of-network plan coverage – this will still allow you to have your surgery. Also ask if we are a preferred provider or non-participating provider. This will determine how much you will be required to pay. 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. Almost all plans require a specialist referral before we can see you. 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.
4. NO insurance companies currently cover intragastric balloon placement procedures.

Once your pre-operative medical work-up is completed and you have fulfilled the insurance requirements, we will submit your records to obtain pre-certification from your insurance company. 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. Document your dieting history. Provide us with the necessary information to submit a strong pre-authorization letter.
2. 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.
3. Although we have a good amount of experience with insurance companies and obesity surgery authorization and claims, this may be a very frustrating process.
4. Patients should take responsibility under the guidance and direction from our office for doing follow-up on the preauthorization submission.
5. 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, 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.
6. We like to get approval the first time! Each insurance company has individual procedures for approval.
7. 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 the key.
8. 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 your personal, professional and social 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.

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