Bariatric surgery and insurance FAQs
How to pay for bariatric surgery
At some point, after you have spent time exploring the option of weight-loss surgery, you will need to determine how to pay for the procedure.
- Read and understand the "certificate of coverage" that your insurance company is required by law to give you. If you do not have one, consult your company's benefits administrator or ask your insurance company directly.
- You may be required to start with your primary care physician. In some cases, he or she is the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care physician.
- Before visiting the bariatric surgeon, organize your medical records, including your history of dieting efforts. They will be valuable documents to have at every stage of the approval process.
- Document every visit you make to a healthcare professional for obesity-related issues or visits to supervised weight-loss programs. Document other weight-loss attempts made through diet centers and fitness club memberships. Keep good records, including receipts.
- If your surgeon recommends weight-loss surgery, he or she will submit medical documentation to obtain pre-authorization from your insurance company. The goal of this documentation is to establish the medical necessity of weight-loss surgery and gain approval for the procedure. The following information is generally included in the pre-authorization request:
- Your height, weight and Body Mass Index (BMI) and any documentation you might have as to how long you have been overweight.
- Simply describing your condition as morbid obesity is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken, and documentation of the effects these conditions have had on your everyday life is necessary.
- A detailed history of the results of your dieting efforts, including medically and non-medically supervised programs, medical records, and records kept of meetings attended with commercial weight-loss programs.
- A history of exercise programs.
Will my health insurance pay for the procedure?
Although most [not all] insurance companies pay for bariatric surgery if the surgery is medically necessary, many of them also require specific criteria be met before giving approval. Please check with your health care plan to determine whether you meet their criteria. If you do not have insurance and are interested in participating in our self-pay, pre-payment program, please call 319-356-1887 for information.
A growing number of states have passed legislation requiring insurance companies to provide benefits for weight-loss surgery for patients that meet the National Institutes of Health (NIH) surgical criteria. While insurance coverage for weight-loss surgery is widespread, it often requires a lengthy and complicated approval process. The best chance for obtaining approval for insurance coverage comes from working together with your surgeon and other experts.
Steps to obtain insurance coverage for bariatric surgery:
- Most insurance companies recognize the health consequences of obesity and cover the costs of the surgical management of weight-loss in qualifying patients. However, every insurance plan is different.
- Because of this, before you start our program, we confirm each policy for bariatric surgery benefits and requirements. If your policy changes at all after starting our program it is very important to confirm the new policy allows bariatric surgery benefits and the requirements on the new plan. Please contact our office as soon as possible so we can assist you with this.
- Once you complete our preparatory program, met all the requirements set by your insurance company, and the surgeon has cleared you for surgery, we start the process to obtain insurance authorization. We begin by sending your medical documentation to your insurance company requesting coverage for the surgery. It can take two to four weeks for the insurance company to respond with a decision.
- We will call you once we receive word from the insurance company of approval or denial. If the coverage is approved, a surgery date and pre-op appointment are scheduled for the patient. If coverage is denied, we review the denial reason and go through the appeal process with the insurance company.
How does the appeal process work?
Even if your initial request for pre-authorization is not approved, you still have options available. Insurers provide an appeal process that allows you to address each specific reason they have given for denying your request. It is important that you/we reply quickly. Some insurers place limits on the number of appeals you may make, so it is important to be well prepared and that you clearly understand the appeal rules of your specific plan.
Why does it take so long to get insurance approval?
After your final consultation is completed and we have all the documentation needed it usually takes one to two days for our specialist to submit to your insurance carrier to start the approval process. The time it takes to get an initial answer can vary from 15-30 days. We will follow up regularly on the approval request. It may also be helpful to call your insurance company to inquire about your request status too.
How can a life-threatening disease be denied insurance coverage?
Payment may be denied because there may be a specific exclusion in a patient’s policy for obesity surgery or "treatment of obesity." You can appeal such exclusions by submitting a personal written request to the benefits manager within the insured’s place of employment and ask for an exception to policy. Insurance payment could also be denied for “lack of medical necessity." A therapy is deemed to be medically necessary when it’s needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments such as dieting, exercise, behavior modification and some medications are considered viable and available. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as physician-supervised dieting or a psychiatric evaluation proving that you’ve tried unsuccessfully to lose weight by other methods.
What can I do to help the process?
Gather any documentation (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide necessary information. Letters from your personal physician and consultants attesting to medical necessity of treatment are particularly valuable. Several physicians reporting the same findings may help confirm medical necessity for surgery.
Once the letter is submitted and 15 days have passed, call your carrier regularly to ask about the status of your request. Your employer or human relations/personnel office may also be able to help you work through unreasonable delays.