Financial
Considerations
Paying for Your Weight Loss
Surgery:
A Discussion of Your Insurance Options
At some point, after you have spent a considerable amount of time
exploring the option of weight loss surgery, you will need to
determine how to pay for the procedure. A growing number of states
have passed legislation that requires insurance companies to provide
benefits for weight loss surgery for patients that meet the National
Institutes of Health surgical criteria. And 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.
Here are some of the key steps you
should take to obtain insurance coverage for weight loss surgery:
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.
To speed up your process, download
and fill out the Patient Profile document.
For more information please call
928
214-3737.
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 prepare a letter to obtain
pre-authorization from your insurance company. The goal of this
letter 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 letter:
Your height, weight and
Body Mass Index 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 description of
the limitations your excess weight places on your daily
activities, such as walking, tying shoes or maintaining personal
hygiene. A detailed history of the
results of your dieting efforts, including medically and
non-medically supervised programs, medical records and records
kept of payments to and meetings attended with commercial weight
loss programs. A history of exercise
programs, including receipts for memberships in health clubs.
Ask your doctor to include
information from medical journals regarding the effectiveness of
weight loss surgery, particularly information showing the control
or elimination of obesity-related health conditions.
Thirty days is the standard time
for an insurance provider to respond to your request. You should
initiate a follow-up if you have not heard from your insurance
company in that time.
The Appeals Process
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 reply quickly. It
also is
recommended that, at this point, you enlist the help of an
experienced insurance attorney or insurance advocate to properly
navigate the complexities of the appeal process. Some insurers place
limits on the number of appeals you may make, so it is important to
be well-prepared and be sure that you clearly understand the appeal rules of
your specific plan.
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SUPPORT IS IMPORTANT
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FINANCIAL CONSIDERATIONS
::
PAYMENT OPTIONS
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