Bariatric or weight loss surgery is often the only recourse for patients who struggle with obesity or morbid obesity and fail to lose weight on their own. Despite the fact that there are other non-surgical options, physicians may recommend weight loss surgery to patients who meet a series of eligibility criteria, including having a Body Mass Index (BMI) higher than 40 or higher than 35 and associated comorbidities like type II diabetes, hypertension, sleep apnea, liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
Not everyone qualifies to weight loss surgery and physicians will evaluate factors like patients’ overall health, psychological state, level of commitment, and incapacity to lose weight with other methods. In addition, patients also need to take into consideration the requirements needed both previously and after the surgery, as well as risks and costs. Health insurance may cover the expenses from weight loss surgery, but it is not completely assured and depends on numerous factors.
Weight Loss Surgery Costs and Medical Insurance Coverage
Bariatric surgery is an expensive type of treatment and it will cost between $20,000 and $25,000 on average, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD). The costs vary depending on the type of surgery recommended by the medical care team, as well as on the surgeon’s fee, which is related to location, expertise and complexity of the procedure, and on the hospital chosen, which will charge for operations, hospital rooms and other fees. In addition, other possible expenses include fees for an anesthesiologist, surgical assistant, medical devices, consultants, and follow-up procedures.
Despite the high costs, patients may find financing to support it. Under the Affordable Care Act, there are states that require health insurance coverage of bariatric surgery and more than half of states currently mandated coverage for individual, family, and small group plans. In 2014, the U.S. Department of Health and Human Services has reduced barriers to obtaining Medicare coverage for obesity treatments. The NIDDKD advises patients to contact staff at their regional Medicare, Medicaid, or health insurance office to find out if the procedure is covered and to obtain facts about options.
Bariatric surgery can be more easily covered by insurance in cases when a patient suffers from at least one comorbidity associated with obesity, is suitable for addressing the patient’s medical condition, and if approved surgeons and facilities are involved. There is currently a greater focus on the importance of fighting obesity in order to treat or prevent related conditions. In addition to improving patients’ health, it can also save on future healthcare expenses — a factor that the research community is continuing to look into.
What to Do to Get Weight Loss Surgery Financing
The first step to have weight loss surgery health insurance is to carefully read the policy and ask the help of the insurer and doctor during the process. Most of the insurance companies will ask for documentation proving that the weight loss surgery is medically necessary, a psychological evaluation to assure that the patient is aware of the procedure and what it involves and to check for binge eating or other psychological problems, a nutritional evaluation to emphasize the dietary alterations needed, and proof of successful participation in a six-month medically supervised weight loss program, which is not required by Medicare but may be recommended as well.
After the patient completes all of these steps, the surgeon will write a preauthorization letter and send it to the insurance company, outlining the medical history, medical conditions associated with weight, alongside documentation that may be needed to fulfill the approval requirements. When all of this is completed, the insurance company will evaluate the case and may request further documents or medical exams to analyze cardiac, pulmonary or sleeping problems. It may be a long process, and patients may face numerous obstacles. As a result, it is important to understand all of the requirements and steps of the process, as well as keep accurate notes of all communications between the insurance company and the surgeon along with copies of all forms and letters.
“Frequently, we may be quick to blame the insurer for lack of coverage. It is important to make a clarification. In order to provide coverage for their employees, companies must purchase a “rider” for weight-loss (bariatric) surgery coverage. Self-insured employers (typically larger employers where the money paid for their claims comes from their own pocket) frequently provide weight-loss surgery benefits. In this circumstance, where the company has elected to provide coverage, the insurance company now applies their standard criteria to those seeking surgery,” clarified Pam Davis, RN, CBN, in a Obesity Action Coalition article titled “What to do When You’re Denied (Bariatric) Weight-loss Surgery.”
What to Do When Weight Loss Surgery Financing Is Denied
If the request for weight loss surgery insurance coverage is initially denied, it doesn’t mean that all hopes for having the surgery covered is lost. The Obesity Action Coalition notes that denials are often the result of fixable reasons such as lack of documentation, which can be sorted out. So, fully understanding the policy and reasons for denial is the first step to contest the decision. Patients can also write a letter of appeal, including an explanation of their point of view, a request for a full explanation about the decision, a request for a copy of the specific statement from the policy or benefits booklet that founds the decision, a copy of the denial notification, and a copy of the preauthorization letter.
Seeking out help from others may also be a good idea. Patients can ask the surgeon’s office for a peer-to-peer review, which means that the surgeon may speak directly with the medical director at the insurance company to review the documentation and point out how the patient meets the criteria. The human resources department at the patient’s company may also help in the process, as well as hiring an advocate like a lawyer specialized in obesity. In addition, patients can also send a copy of their appeal letter to their state’s insurance commissioner or the department of corporations in the case of an HMO plan, explaining the problems faced and asking for assistance.
When patients face a final decision of financing denial, they will likely have to pay the expenses themselves. In these cases, patients may enquire about bariatric surgery costs at weight loss surgery centers for the possibility of having the fees spread out over a number of years. As an alternative, patients can also do some research and locate a Bariatric Surgery Center of Excellence program and a surgeon who offers a comprehensive program at a reduced self-pay (cash) rate that includes coverage of complications or readmissions through the BLIS program.