Insurance Concerns and Paying for Surgery

After exploring the options of bariatric surgery, you will need to determine how to pay for the surgical procedure. For many people, bariatric surgery is affordable because it is covered by their health insurance plan. People who do not have insurance coverage for bariatric surgery must pay for it on their own. Although patients often consider it a critical investment in their health, it is very expensive.

Whether you have health insurance or opt for self-pay, you will need to prepare detailed written documentation. Documentation is very important and you should include everything from diet history to co-morbid conditions; this information will come in handy.

Working with Health Insurance

Increase your chances of obtaining approval for insurance coverage by working with your bariatric surgeon, your bariatric program, and your insurance provider. Provide them with as much information as you can. Include paperwork, medical records, receipts, etc.

Many people find dealing with health insurance companies to be intimidating and are not sure how to even get started. If you are thinking about bariatric surgery, consider the following: Read your Certificate of Coverage (COC). A COC describes your insurance policy in detail, including what it covers and what it excludes. Write down your weight loss history. Go as far back as you can and include diets and exercise programs. If possible, pull together receipts for gym memberships and weight loss programs.

Keep ongoing documentation of: previous weight loss attempts including medically supervised diets, weight loss programs, and gym memberships, co-morbid conditions, current medications, visits to healthcare professionals for obesity-related issues and how morbid obesity affects the quality of your life.

Appealing a Denial

If the insurance company turns down your request for bariatric surgery, you may be able to appeal the decision. You can start by writing a description of how morbid obesity decreases the quality of your life. Be sure to include details such as difficulty walking, socializing, or maintaining personal hygiene. This documentation can be useful for your bariatric program and health insurance company.

Read and Understand Your Policy – The policy is a legal contract, so understand your rights and responsibilities. It will list the benefits the insurance company will and will not cover. If anything is unclear, get clarification from your insurance agent or company. If you are insured by a group policy through an employer, you will receive a certificate of coverage. The certificate of coverage will list benefits and your rights and responsibilities. Know which services require authorization prior to the treatment or service being obtained. Failure to obtain prior authorization will most likely result in a denial. Services that commonly require prior authorization include such procedures as elective surgery and MRIs.

What to Do if a Claim is Denied During Treatment – Contact your insurance company immediately. Keep notes of all conversations. Include the name of the person with whom you speak and the date and time of the conversation. Listen carefully and make note of the answers you get. In addition, check your policy or certificate of coverage to determine your appeal or grievance rights. Make note of time frames in which you must appeal a decision. Be sure that you do not exceed any time limits.

Be Persistent – Sometimes a simple error may have caused a denial. A billing error or incorrect code may have been entered. This type of error can often be cleared up quickly. If, after your initial conversation with the company, your claim is refused, be persistent.

Insurers and HMOs are required by law to provide a written explanation of benefits (EOB) which must include a specific explanation of any denial, reduction or other reason for not providing full reimbursement. The EOB must also include a telephone number or address where an insured can obtain information on how to file an appeal. An appeal should be filed as soon as possible; don’t wait because there are specific deadlines within which an appeal must be filed.

What to Do If an Insurer Continues to Deny a Claim – Generally, you should first submit a letter to the company requesting that your claim be reconsidered, giving specific reasons why you believe the claim should be paid. Be as detailed as possible, explaining why your procedure or medication is needed. Make arrangements with your medical provider to have medical records, x-rays or lab results sent to the insurer to support your position. Be sure to keep a copy of everything for your records. Your insurer must respond, indicating the next steps in the process.

Know Your Rights – If a health insurer denies or limits a medical service because it is considered experimental, investigational or not medically necessary, you have a right to appeal the decision. Request the insurer conduct an internal appeal to reconsider its decision. If you disagree with the result, contact the Insurance Department and request an external appeal conducted by a medical professional not affiliated with the insurer. You must request an external appeal within 45 days of the insurer’s decision on the internal appeal. The Insurance Department will review your request for an external appeal within five business days and, if the request is eligible and complete, assign an external appeal agent to review the matter. A decision will be made within 30 days. There are provisions which allow for an expedited appeal if the services have not yet been provided and a delay in providing them would pose an imminent or serious threat to the patient’s health. A decision on an expedited appeal must be made within three days.

Possible Options After Appeals

Even if you exhaust the appeals options, you still may have options:

Independent review board: This is an option available to people in more than 40 states and doesn’t require a lawyer. Judgments usually are issued in 60 days. Check your state’s website for specific filing instructions.

Arbitration: Some health insurance companies require patients to use a third party—other than the patient’s lawyer and the insurance company—instead of going to court.

Litigation: This option is expensive and takes a lot of time.

How to Advocate for Coverage

Health insurance is one of the most common benefits offered by employers. Large employers often have self-funded health insurance and decide which health services and procedures are covered under their policy. If this is the case, there are steps you can take if your employer has decided not to include bariatric surgery as a covered benefit. Meet with a Human Resources Representative Take time to meet with someone from Human Resources to find out why bariatric surgery is not covered. Share your story and how you believe bariatric surgery will benefit not only you, but your organization as well. It may be helpful to bring information about the many benefits of bariatric surgery—such as increased energy levels and decreased health issues—which can translate into savings for the employer. Educate Coworkers Getting coverage approved by an employer can be a time-intensive process. Take the time to educate your coworkers about the surgery and its importance. By educating your coworkers, you’re not only fighting society’s obesity bias, but you also may find other people interested in bariatric surgery.

If your family or friends are unsupportive, take a few moments to talk to them further. They may only know the myths of bariatric surgery. Explain to them why you are considering bariatric surgery and share with them risks of surgery. Consider taking them with you to a support group. That way, they can hear firsthand from bariatric surgery patients and learn about their experiences.