What to know about insurance
At some point, after exploring if weight loss surgery is the right choice for you, you will need to determine what payment options are available to you and where you will have surgery. The majority of insurance companies cover weight loss surgery also known as bariatric surgery. Presently insurance companies cover all the weight loss operations: Lap-Band, Sleeve, Bypass and the Duodenal Switch as well as revisional surgery (repairs and alterations). Medicare, Medicaid, and local Kansas BCBS are the latest insurances to cover weight loss surgery. Working with your insurance provider for coverage of bariatric surgery can often be a difficult task. Your insurance policy may or may not cover bariatric surgery and such coverage varies widely depending on your location and employer. Our bariatric practice has a dedicated staff to help you navigate your insurance policy and obtain pre-approval. Many insurance companies also demand that the doctor and/or facility be a center of excellence or a MBSAQIP Accredited Center.
When deciding where to have metabolic or bariatric surgery, patients have many options. One significant choice to make is whether you will have your surgery at an accredited or a non-accredited facility. In making this choice, it is critical for patients and referring physicians to understand what makes a facility “accredited”, and why that accreditation is so important. The bariatric and metabolic surgery accreditation process is called MBSAQIP, which stands for Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. MBSAQIP was developed jointly by the American College of Surgeons and the American Society for Metabolic & Bariatric Surgery, to foster patient safety and surgical excellence. To become accredited, a facility undergoes a rigorous process of evaluations to ensure their level of quality across safety, training, follow-up, and surgical volume standards. A recent study showed that the mortality rates at non-accredited facilities are on average three times greater than the mortality rates at accredited facilities. Accreditation is an important, life-saving process and we encourage patients and referring physicians to seek out those facilities that meet these rigorous standards. The Minimally Invasive Surgery Hospital is a MBSAQIP Accredited Comprehensive Center.
Weight Loss Surgery Insurance Coverage
Often patients are misled by the wording in their insurance policy manual and believe it is not a covered benefit. Our staff is well versed in the insurance language of weight loss surgery benefits. The best way to verify coverage for us is by reading the actual weight loss surgery section in your policy manual. If that is not available our staff can call your insurance and verify your coverage that way. Calling is the least reliable method (unfortunately the insurance reps can provide inaccurate information).
Once coverage is verified, our office will take care of all the paperwork involved in submitting for surgery pre-authorization to your insurance company. Sometimes your insurance's first response will be "while the patient has benefits for weight loss surgery we will need more information...” That means there are more insurance company criteria to meet. The additional information will need to be re-submitted for them to pre-authorize. Our staff will work with you till you have received the pre-authorization letter in your own mailbox.
Even though our office will facilitate the entire pre-authorization process for you, we still want you to fully understand how your insurance company covers weight loss surgery. It is very important to understand your insurance company. Below is some basic information on how to successfully obtain weight loss surgery coverage and/or pre-certification from a medical insurance company.
Insurance Companies that we have worked with and obtained pre-authorization from are: GEHA, United Healthcare, Aetna, BCBS, Freedom Network, CIGNA, Medicare, Missouri Medicaid, Assurant Health and more.
Before making your first office visit please read the two points outlined below:
1. Your first step should be to determine whether your specific insurance policy covers weight loss surgery (also known as obesity or bariatric surgery). If it does not the next question is, does your insurance company offer other policies or riders covering weight loss surgery? If you do not have coverage your insurance may make you responsible for any charges related to weight loss surgery, even a first visit with the surgeon. If your insurance company will not cover any weight loss surgery, your remaining options are: to change your insurance company, investigate your spouses insurance company, contact your congressman or lawyer for help, or make payment arrangements. Often a letter from a congressman or lawyer has helped in the past when the insurance company placed unreasonable hurtles despite covering weight loss surgery. You can also give us a call. If you provide us with your insurance information we can call on your behalf and verify whether or not you have coverage, and/or investigate what kind of documentation of "medical necessity" is required.
2. Please verify if the surgeon/facility are in-network, out of-network, preferred or non-participating providers. Your insurance company is the most reliable and capable source of explaining provider participation. Many find the terminology confusing, and it is very important to have a clear understanding of these terms. How the insurance company deals with the provider or facility will determine how the claims will be paid out. We strongly recommend spending time researching and understanding this information before entering into any weight loss surgery program. Some insurance companies may not allow you to seek care from an out of-network provider or facility, unless the provider or specialist you have been referred to is not available within the insurance companies own physician network. In this circumstance the insurance company will usually treat the specialist as an in-network provider. Always ask for important information in writing. The more familiar you are with your policy and your insurance practices the fewer unexpected bills you will receive. Bottom line, if you do not have weight loss surgery coverage you may be responsible for all bills related to weight loss surgery.
Insurance Qualifying Criteria
Different insurance companies have different surgery qualifying criteria. Some insurances will only require that the patient meet weight criteria, others may need to have certain type of medical problems, and proof of past dieting attempts. Below we will attempt to list the more commonly seen insurance qualifying criteria that we have come across that patients may have to meet in order to obtain pre-authorization for their operation.
MOST commonly seen insurance criteria:
- BMI > 35 with co-morbidities
- BMI > 40 with or without co-morbidities
- Documentation of a Medically Supervised Program (specifics vary broadly)
- Exercise Program under supervision
- Proof of Morbid Obesity over the last 5 years
- Proof of co-morbidities (2 yrs of medical records)
- Nutrition Consultation
- Psychiatric Consultation
- Medical doctor clearance for surgery
1. Start collecting relevant medical records which document any co-morbid conditions you have such as: high blood pressure, diabetes, reflux, sleep apnea, urinary stress incontinence, degenerative weight bearing joint disease and other weight related co-morbidities.
2. Obtaining dieting records can be as important as obtaining your medical history records. A “Medically Supervised” diet and sometimes exercise program is a term the insurance companies are using to define an adequate dieting attempt. These include prescription drugs and other dieting programs supervised by a physician, nurse or dietician, and exercise programs overseen by a physician, therapist and/or trainer. The quality of dieting documentation has been the most common reason why obesity surgery pre-certifications have been denied despite available coverage. Presently most insurance companies are demanding documentation of a diet program of at least 6 consecutive months in length under medical supervision or a 3 month surgery preparatory regimen program thru a weight loss surgery program. Do not ignore commercial weight loss efforts such as Weight Watchers, Jenny Craig, etc. Although these records can be difficult to obtain (receipts, registration papers, etc. ), these records can be regarded as "medically supervised" diet attempts that an increasing number of insurers are recognizing.
3. Often excess weight can have an impact on patient lifestyle. Limited mobility secondary to joint and/or back pain is the most common. If you are able to provide a detailed description and documentation of the lifestyle limitations your excess weight places on your daily basic activities, such as walking, tying shoes and so forth, it can be helpful swinging information for their consideration. Also such issues as maintaining personal hygiene and similar related problems are worth mentioning.
4. Do not be afraid to approach other patients about their pre-certification experience at seminars or chat rooms on the web. There is no better place to gather 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 years with weight loss surgery pre-certification and obesity surgery claims we continue to learn new things every day.
5. Once all your insurance criteria have been met the doctor will write a letter of "Medical Necessity" to your insurance company requesting pre-authorization and documenting medical necessity based on your medical history, life style limitations, and dieting history records. The insurance company mails the patient and the doctor their decision or need for more information.
6. We believe the most important thing that a patient can do to get surgery approval is to be persistent and aggressive when talking to their insurance company. Too many people let insurance companies win the battle and the war because they gave up too soon. Know your insurance company and get it in writing when you receive important information.