Many times patients who do not have coverage for weight loss surgery will ask us to file an appeal. Will this work? The short answer is no. Read on for the long answer…
If your insurance does not cover weight loss surgery, this is called an “exclusion.” This means that the employer who provides the insurance chose to exclude surgical weight loss from coverage in order to purchase a cheaper plan. Once you understand this fact, it’s easier to understand why you can’t file an appeal and get them to cover it, no matter how severe your obesity might be.
If insurance companies were to allow this, then no employer would ever opt for the more expensive plans that do cover bariatric surgery. They would just buy the bare bones coverage and then tell their employees to all file appeals to get it covered anyway.
Unfortunately, when patients call their carriers, someone on the other end of the line (who actually works for the insurance company) will tell you that you can file an appeal. This is technically true, as you can file an appeal for anything your insurance denies. However, in this case the appeal will never work because the issue is not one of medical necessity; in otherwords the insurance company is not saying that you don’t need the operation, they are denying it because you do not have the right type of coverage. It would be somewhat like having a tree fall on your house and asking your car insurance to pay for it. Or, perhaps more appropriately, asking your homeowners to pay for flood damage when it is specifically excluded from your homeowners policy. It simply isn’t going to happen.
Also unfortunate (at least in Ohio, Kentucky and Indiana) is that marketplace policies purchased by individuals under the Affordable Care Act also exclude weight loss surgery. Medicare, Medicaid, and most managed-care Medicaid plans such as CareSource, do cover weight loss surgery, however.
We wish that all Americans had access to life-saving surgical weight loss procedures, and maybe some day that will happen. In the meantime, patients with exclusions essentially have two options:
- consider self paying for surgery
- look into a more affordable option such as one of our appetite suppression programs
Frequently Asked Questions (FAQ) about Bariatric Weight-Loss Benefit Exclusions:
- Why do I have a bariatric weight-loss benefit exclusion? When employers decide on a policy to offer their employees, they determine if they want to include or exclude bariatric weight-loss benefits. It is an addition to a plan; it is not an automatic benefit for a medical health plan.
- What happens if the practice submits a pre-authorization when my insurance policy has a bariatric weight-loss exclusion? If the practice submits a pre-authorization and gets approval for medical necessity, it may seem the patient is approved for surgery. But when the patient’s policy does not have bariatric weight-loss benefits, the insurance company will not pay the claim. This will make the patient responsible for the entire billed amount, possibly over $50,000.00. If the pre-authorization is denied, you would have to possibly complete extra insurance policy requirements, which you did not need when you have a bariatric weight-loss exclusion. Some insurance policy requirements are but not limited to, a body mass index (BMI) of over forty (40), 5-year weight history, and a twelve-month physician-supervised diet.
- Why does the practice maintain a Self-Pay Financial policy not to submit a pre-authorization for a policy with an exclusion? When a practice submits a pre-authorization to an insurance company, they are checking to see if the patient is approved, medically, for surgery. This is called medically necessity. The insurance company pre-authorization department does not always verify if a policy has bariatric weight-loss benefits. Therefore, we do not submit for medical necessity when a patient has a bariatric exclusion.
- Why do I not have to meet my insurance bariatric weight-loss policy requirements when I have a bariatric exclusion? Each insurance company has a bariatric weight-loss policy with requirements to meet medical necessity; this is to qualify the patient medically. When you are not using your insurance for bariatric weight-loss benefits, you do not need to meet their guidelines. You do have to meet the JourneyLite Physicians Self-Pay guidelines.
- Why am I waiving the right to file a claim? If you have a bariatric weight-loss exclusion, your claim will be denied, and you will be financially responsible up to $50,000.00.
- Why should I continue as a Self-Pay patient? JourneyLite Physicians is a bariatric specialty group. Each and every day we work hand in hand with insurance companies to review their bariatric weight-loss policies and guidelines. We have created a partnership with them and would like to create this partnership with you also. If you have an insurance bariatric weight-loss exclusion, we want to help you through having surgery. It is very important for us to guide you or your loved one that is having surgery. We are here for you!
