Insurance can be drawn out and frustrating for you, and our experience can help, but so much relies on your individual policy. Here are some common questions patients have concerning insurance:
All carriers and all insurance policies have different coverage guidelines and different exclusions. You might try asking your insurance company, "Is weight loss surgery a covered benefit for the treatment of morbid obesity, diagnosis code 278.01?" You may get an accurate answer, but you may have to speak to several different people before someone will actually look into your specific policy.
After we submit the letter of pre-determination, most insurers have a standard time that they are allowed to process a non-emergency request, usually up to 30 days. Most insurers take the maximum time.
We’re familiar with the criteria and guidelines of most insurance plans and, if necessary, we’ll research your insurer's requirements. But we encourage you to get involved in the process and call your insurance company regularly about your request. If you have questions, please call your carrier. When we hear from your insurer, we’ll contact you right away.
A letter of pre-determination or pre-certification from your insurance company means their medical review department has decided, based on the information provided, that your surgery is medically necessary. But this does not mean they will cover your surgery. That depends on your individual insurance policy.
We will submit the necessary documentation to your insuance company. Please do not ask any other physican to submit anything directly to your insurance company. They can provide necessary documentation to us, and we will submit everything as the insurance company requires.
You may have a specific exclusion in your policy for obesity surgery or "treatment of obesity," which reflects the prejudice of our society toward obesity. This exclusion normally cannot be challenged or overturned. You may be able to get an exception by going through your employer's benefits division.
Coverage may also be denied for lack of "medical necessity,” meaning it’s not deemed a serious or life-threatening condition. Instead, alternative treatments, such as dieting, exercise, behavior modification, and some medications, may be considered to exist according to conventional wisdom. To avoid denials for this reason, be sure to include reasonable, thorough documentation to encourage them to approve your request.
First, help us to get all your information together (diet records, medical records, medical tests), so the carrier cannot deny for failure to provide information. Letters from your physician and consultants attesting to the "medical necessity" of treatment are particularly valuable.
After we submit the pre-determination letter, we encourage you to call your carrier regularly and ask about your 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.
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.
It is important to understand the terms, conditions and limitations of your coverage. If you have questions about your coverage, contact your employer's human resources department or your insurance company directly.