Insurance

Benefit Investigation Guide

Obtaining insurance coverage for Bariatric surgery is often the most difficult and frustrating part of the entire process.  Some insurance companies make it very easy for their enrollees to obtain Bariatric Surgery, others make it nearly impossible.  Talk to the surgeon’s front desk team and ask if they often have trouble getting authorization from your insurance company.  Often the office staff will know better than the surgeon.

Most insurance companies require a period of pre-operative, physician supervised weight loss.  Often, patients are referred back to their primary care doctor, however some programs, like mine, will offer the counselling through their practice.  Many patients look at the physician supervised weight loss period as something that must be done to satisfy the insurance company’s requirements.  For many patients, these months preceding the surgery can be an excellent opportunity to prepare for life after surgery.  I work with my patients and make one, meaningful change to their diet each month.  After a few months, patients have increased their vegetable intake, decreased their sugar intake, eliminated all sugar sweetened beverages, limited artificial sweeteners and made many of the changes that are required for success after surgery.  

Most insurance companies also require a psychological evaluation prior to surgery.  This requirement is not grounded in solid scientific evidence, but it remains a staple of the preoperative requirements for nearly every insurance plan in the United States.  The psychological evaluation typically consists of answering hundreds of bubble sheeted questionnaires designed to determine if you exhibit impulsive or compulsive behaviors, suffer from eating disorders, are suicidal, have a substance abuse disorder or exhibit any other tendencies believed to pose a risk to your postoperative success.  Usually, the evaluation can be accomplished in an afternoon, however, many psychologists will require a number of follow up visits which often coincide exactly with the amount of insurance coverage you have for these types of treatments.  

I’ve noticed tremendous variation in the quality of pre-operative psychological evaluations.  Many patients report the experience as very helpful and established a relationship that they can lean on after surgery to help deal with postoperative adjustments.  However, an equal number of patients often report that the evaluation was tedious, unnecessarily long or expensive.  Again, the front desk staff at your Bariatric Surgeon’s office can be very helpful in helping you determine which psychologist you should see.  There are also several online services that will complete an evaluation over the phone.  While I question the value of what often amounts to a short phone call, I also recognize that not all prospective patients need the psychological evaluation that their insurance company requires.  For those patients without clinically significant depression, a history of a substance abuse disorder or suicide attempts who are generally doing just fine in the rest of their life, but just need help losing weight, an online service may be your most convenient option.

If you are denied for your Bariatric procedure, don’t panic, you still have several options available to you.  The first step is to determine why you were denied coverage – the insurance company is forced to provide a reason.  If it is a simple matter in which the appropriate documentation was not provided in the initial request, a peer to peer evaluation in which your surgeon speaks to a physician who works for the insurance company can usually remedy this situation.

There are several insurance companies that set requirements that are nearly impossible for most patients to satisfy.  Many of the insurance companies that provide Medicaid services and United Health Care are particularly difficult to get to approve Bariatric Surgeries.  Many patients respond to denials with appeals that Bariatric Surgery will improve their health and prevent them from developing heart disease or diabetes. While this is certainly true, when appealing to insurance companies for coverage, it is unfortunately, completely ignored.

Health insurance is a legal contract between the insurance company and you, the beneficiary.  This legal contract explicitly states which services are covered, and which services are excluded.  For those covered services, the contract states what steps must be fulfilled in order for the insurance company to be obligated to pay.  This is a legal contract, so moral or medical appeals will be ignored.  The hard truth about health insurance is that appeals for coverage based on your health are considered with as much importance as a plea to your mortgage lender that you can’t make your payment this month because you’re short on cash.

Because this is a legal contract, not a moral obligation, your appeal must be based on satisfying the requirements stated in the contract, not on the ways the surgery will benefit you.  There is a very helpful and fair company that can assist you in your appeal that is run by a passionate Bariatric Surgery patient, Walter Lindstrom.  Walter’s company can be found online at www.wlsappeals.com at has extensive experience successfully battling insurance companies for weight loss surgery coverage approvals.  The website also offers a wealth of information about insurance coverage for Bariatric Surgery.  

While most insurance companies will eventually cover Bariatric surgery, there are many people whose policies specifically excludes coverage.  This unfortunate group still has options, but it can get expensive.  As of 2016, there are policies on the healthcare.gov that cover Bariatric Surgery, however this will vary from state to state.  Often there is a high co-pay with these policies and a waiting period, but it is usually less expensive than paying for the entire procedure out of your pocket.

For those who elect to pay for their procedure out of pocket, there are several companies who offer financing for these procedures.  Most commonly, people use Care Credit (carecredit.com) and Prosper Healthcare (prosperhealthcare.com) to finance their procedure over 3-5 years.  A Sleeve Gastrectomy typically costs between $12,000 to $15,000 and a gastric bypass procedure is typically $3,000 to $4,000 more than the sleeve prices.  Choosing to self pay for your surgery also limits the number of selections that you have since many hospitals do not have affordable programs set up.

If you have complications after a self pay operation, this can have devastating financial implications.  For those patients who have health insurance, but do not have Bariatric Surgery coverage, your health insurance plan still may pay for coverage for complications, even if they don’t cover the surgery.  For those that don’t have insurance coverage, if you are unfortunate to suffer a significant complication, you can find yourself in debt for a huge amount and your only recourse may be to declare bankruptcy.  Blis (www.bliscompany.com) offers insurance coverage in case of complications in case you are in the 1-2% of people who have a complication after surgery.  

Just as obesity is a chronic disease that develops over years, the road to weight loss surgery occasionally takes several years.  If you are faced with insurance obstacles that seem insurmountable, or the self pay option is completely unaffordable, you may have to put aside your plan for surgery for now.  Insurance plans are constantly changing and a market is developing for lower cost self pay procedures.  Don’t despair if you are unable to proceed with surgery.  Perhaps this setback is providing you an opportunity to focus more on your lifestyle habits, making you a better prepared patient for next year when your insurance coverage changes.

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