Obesity rates among adults have skyrocketed in America. This excess weight causes major health problems. When diet and exercise fail, many people look to bariatric surgery to help them lose weight.
However, these surgeries can be expensive if they are funded completely out of pocket. Therefore, we have put together some tips to show you how to get weight loss surgery approved through your insurance company.
Weight Loss Surgery
Bariatric surgery encompasses any surgeries on the stomach. These include gastric bypass, laparoscopic adjustable gastric banding and biliopancreatic diversion.
These operations dramatically restrict a person’s ability to eat. The smaller stomach can only hold a few ounces.
As a result, they can lose weight. Some weight-loss surgeries also alter the digestion process. This limits absorption of calories as well as nutrients.
Benefits of Weight Loss Surgery
Aside from the obvious, there are many benefits to weight loss surgery. The American Society for Metabolic & Bariatric Surgery says that people who undergo the surgery can increase their life expectancy by up to 89 percent.
Many of the obesity-related issues that patients suffer with are greatly improved with surgery.
Sleep apnea, high blood pressure, asthma, arthritis, fatty liver disease, cholesterol abnormalities, gastroesophageal reflux disease, urinary stress incontinence and venous stasis are all common issues for obese patients. However, weight loss surgery can improve, or eradicate, all these issues.
Does Insurance Cover Weight Loss Surgery?
The average cost for bariatric surgery is between $17,000- $26,000. Even if the coverage is available through your insurance policy and your doctor recommends the procedure, your health insurer might not pay for the surgery.
ASMBS says that insurance denial was one of the most common reasons that people decide not to have the surgery. Furthermore, roughly 25 percent of patients are denied coverage at least 3 times before getting approval for the surgery.
Unfortunately, it is common to find that health insurance companies refuse to pay for weight loss surgery.
On the other hand, they are willing to pay for years of treatment for conditions associated with obesity. Seems ridiculous, right? It is becoming evident that surgery for morbid obesity could be much more cost effective that treating the conditions that result from obesity.
How to Get Weight Loss Surgery Approved
While it is unlikely that you will find an individual health plan that covers weight loss surgery, especially if you are already overweight, it is still possible to get the surgery covered. The best chance is to go through a group health plan.
However, standard plans do not cover bariatric surgery. The employer must specifically select it as an option. The six states that mandate treatment for morbid obesity be covered by group health plans are Maryland, Illinois, Georgia, Indiana, New Hampshire, and Virginia.
First, you need to know your policy terms. Is bariatric surgery specifically excluded in your policy? Do you need pre-authorization? Your insurer will most likely require pre-authorization, documented physician supervised weight loss attempts, and a full medical work up.
However, insurance plans rarely cover weight loss programs and Weight Watchers and Jenny Craig do not count. When you make the pre-authorization request, you will find out exactly which documents you need. Expect it to be a lot.
Other Strategies for Coverage
- Change to a spouse’s plan if it provides coverage
- If your HMO plan does not offer coverage, change to a PPO plan that covers the surgery.
- Considering getting a job with employers who offer coverage. According to ASMBS Intel, Toyota, FedEx, Freight, Microsoft, and Harrah’s and Caesar’s Palace offer coverage to your employees.
- As a last resort, you can consider paying out of pocket and speak to the surgeon’s office about payment plans and financing.
If You Get Denied
First, if your plan offers the coverage but your request is denied, appeal it. You may be required to provide further documentation of your need for the surgery as medically necessary. Your plan should have a clear appeals process.
So, find out what it is and follow the instructions. Importantly, there is typically a time limit for filing an appeal. So, get the process started as soon as possible.
Second, ask for your surgeon’s assistance. They should be able to help you with solid documentation.
Also, some surgeon’s offices have an appeals expert that has experience getting claims paid for, even after denial. Furthermore, you should keep meticulous records of your appeal and all interactions with the insurer.
Weight Loss Surgery Maryland
If you are interested in having weight loss surgery and would like more information on how to get your insurance provider to cover it, contact Maryland Bariatrics today.
