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> Insurance Issues Frequently
Asked Questions about Morbid Obesity, Gastric Bypass Surgery, Gastric
Banding and Weight Loss
Insurance Issues related to Gastric Bypass
surgery:
 How long does it take to schedule surgery?
Why does it take so long to get insurance approval?
What is a letter of pre-determination or pre-certification?
How can they deny insurance coverage for a life-threatening disease?
What can I do to help the process?
What questions should I ask my insurance company?
Where to go for answers
How
long does it take to schedule surgery?
Our program requirements include medical tests, education, and psychological
support. Depending on the response from one's insurance company, it's
generally 2 to 6 months from the time patients attend their first
information lecture until their surgery date. Insurance approval is
a prerequisite for many people and we can ordinarily schedule surgery
within about 4 - 6 weeks after financial arrangements are made. When
we obtain insurance approval we contact you to determine if, and when,
you wish to schedule surgery. We recommend that you do not wait more
than about 90 days after insurance approval is granted or re-approval
may be needed.
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Why
does it take so long to get insurance approval?
From the time we receive
your completed application packet, it usually takes us 1 - 2 days
to send a letter to your insurance carrier to start the approval
process. Typically it takes 3-8 weeks for a decision from insurers.
Our insurance analysts follow up regularly on approval requests.
We are familiar with the criteria and guidelines of most insurance
plans and if necessary we will research your insurer's requirements
before sending your letter of predetermination. Our goal is to submit
everything the carrier requires at first contact in order to facilitate
a timely approval. We will contact you when we have any news on
the status of the approval request, so if you have questions we
ask that you call your carrier. We encourage our patients to get
involved in the process and call their insurance companies regularly
regarding the approval process.
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What is a letter of pre-determination
or pre-certification?
A letter of pre-determination
or pre-certification from your insurance company means that a medical
review department within your insurance company has decided, based
on the information provided, that your surgery is medically necessary.
However, this does not guarantee your insurance company will cover
your surgery. The medical review department does not review the
terms of your individual insurance policy. It simply determines
whether or not the surgery is medically necessary.
It is important for you
to understand the terms, conditions and limitations of your insurance
coverage. If you have questions about your coverage, contact your
employer's human resources department or your insurance company
directly.
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How can they deny insurance coverage for
a life-threatening disease?
Coverage may be denied because there is a specific exclusion in your
policy for obesity surgery or "treatment of obesity," which
is manifestation of the attitude of our society toward obesity, and
the discrimination which obese persons suffer. Such an exclusion can
be challenged by the reasoning that the surgical treatment is recommended
as the best therapy for the co-morbidities, treatment of which is
usually covered.
Coverage may also be denied for lack of "medical necessity."
A therapy is deemed to be medically necessary when it is needed to
treat a serious or life-threatening condition. In the case of morbid
obesity, alternative treatments are considered to exist – according
to conventional wisdom – such as dieting, exercise, behavior
modification, and some medications. Usually medical necessity denials
hinge on the insurance company’s requirement of some form of
documentation, and the best approach is to try to produce reasonable
information to encourage them to approve payment for the procedure.
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What can I do to help the process?
First, help us to get all
the information (diet records, medical records, medical tests) together
in your case so the carrier cannot deny for failure to provide necessary
information. Letters from your personal physician and consultants
attesting to the "medical necessity" of treatment are
particularly valuable.
After we submit the pre-determination letter, we encourage patients
to call their carrier regularly, to ask about the status of the
request. You may also be able to protest unreasonable delays through
your employer or human relations/personnel office.
Keep in mind that most
doctors and hospitals require that patients pay a large portion
or all of their co-payments and deductibles before surgery. Patients
need to be prepared financially and be aware that they may receive
bills from doctors, the hospital, the anesthesiologist, and any
other health care providers involved with their case.
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What
questions should I ask my insurance company?
1. Does
your insurance pay for this type of surgery?
2. Does
your insurance pay for this diagnosis, in other words, the reason
you are having the surgery?
3. Is
the doctor performing the surgery a participating provider with
your insurance network?
4. If
your surgeon is not a participating provider, will your insurance
cover out-
of-network providers? Will they pay less for out-of-network doctors
and does this mean you will
have to pay a larger portion of the bill – or maybe all of
it?
5. Does
your primary care doctor have to refer you to the surgeon?
6. Does
your insurance require any special referrals or authorization?
7. What
hospitals are in your insurance network?
8. Do
you have a co-payment and what is your deductible?
9. Do
you have co-insurance?
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Where to go for answers:
The customer service number for your insurer will be on your insurance
card. You can also visit the insurance company's website, read the
most recent insurance handbook from your employer or insurer, or talk
to your supervisor or human resources department for questions about
your health insurance.
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