Figuring out if you have coverage for weight loss surgery is not the easiest task.
Here are some insurance tips for weight loss surgery coverage from the team at JourneyLite!
JourneyLite Physicians is in-network with almost every major private insurance company! This includes:
- Aetna – JourneyLite is an Aetna Institue of Quality
- Anthem
- Blue Cross-Blue Shield
- JourneyLite is a Blue Distinction Plus Center
- Cigna
- Humana
- Medical Mutual
- Surgery Plus
- Transcarent
- United Healthcare
- JourneyLite is an Optum Center of Excellence
If you’re insurance company is not listed here, check with us, as this is not a comprehensive list!
Knowing if we are in-network is not the first step, however. If you are going through insurance, first you have to check to see if you have bariatric surgery as a covered benefit in your plan. Despite the fact that weight loss surgery is endorsed by the National Institutes of Health as the only effective treatment for morbid obesity, some insurance policies do not cover it at all. When this occurs, typically it is called a plan “exclusion.” With an exclusion, there are no appeals that can be made to get your plan to cover these procedures. This decision is made when your employer providing your insurance buys the plan. Therefore, it is very important to make sure “you” have the benefit on your particular plan. Here are some important insurance tips for weight loss surgery!
Obtaining insurance authorization involves some (or all) of the following steps:
- Confirming with your insurance that surgical weight loss is a covered benefit on your policy.
- Determining which surgical weight loss procedures your policy will cover.
- Determining what criteria will be needed for insurance approval (BMI, weight, if you need 3-18 months previous weight loss attempts, etc).
- Obtaining documentation with 2-5 years of medical records from your primary care physician.
- Clearance from a mental health professional (psych eval).
If you have the benefit and meet your plans criteria, our office will prepare a letter of medical necessity outlining your situation. We will submit it along with all the necessary information requesting approval for your weight loss surgery.
You will need to take an active role in gathering this information, starting by contacting your insurance!
When you do this, be sure to document every step of this process. It is becoming increasingly difficult to obtain insurance coverage for weight loss surgery with some insurance companies. Some insurance companies put up hurdles for patients, like requiring you to have participated in a physician-supervised weight loss program before approval.
- BE INFORMED
Do your research! There are several internet sites where you can go and gather useful tips on how to be prepared. For example, ObesityHelp.com has some useful information. Some patients even recommend the book “Weight loss surgery for dummies” and have found it helpful.
- PERSONAL INFORMATION
When you call your insurance company, you should know:
- your height
- your weight
- your BMI (there is a BMI calculator here)
- your weight-related medical problems (these are often referred to as co-morbidities.)
- your previous diet history
Some primary care physicians will want to write a letter recommending surgical weight loss to the insurance company. Rather than having your doctor send that to your insurance company however, it’s best to give that to us! We can then include it with our letter. We will need medical records from your primary care physician and any prior weight loss attempts.
- MAKING THE CALL TO THE INSURANCE COMPANY
It is important to make contact with your insurance company to find out if surgical weight loss is a covered benefit, what procedures they will approve, and if you can select the surgeon you want. You should call the customer service line on the back of your card or call your benefits coordinator at your human resources office.
Please use the list below to help you ask all of the questions and to document the answers received from your insurance company.
- Is surgery for morbid obesity a covered benefit?
- Write down the exact telephone number and extension called, and the exact name of the contact person you spoke with.
- Call the customer service number on the back of your insurance card.
- State “ I am inquiring about my benefits for surgical weight loss for morbid obesity (Diagnosis code or ICD 10 code E66.01).”
- Are these CPT codes covered?
- 43770 Gastric band
- 43644 Gastric bypass
- 43775 Gastric sleeve
- SIPS/SADI does not yet have a CPT code and will not be covered.
- Do I need
- Medical clearance from the Primary Care Physician?
- Documentation of length of obesity?
- Documentation of weight loss attempts?
- Is Dr. Curry (NPI #1841281987 in network?
- If not, do I have out of network benefits?
- Do I need
Remember to be sure and get the name and the extension of the person that you talked to!
- START MAKING APPOINTMENTS
- Initial Office Consultation
If you don’t have an initial consultation already scheduled with us you can request one here. You will receive an email with a link to log in to your patient portal. Fill out the MEDICAL HISTORY & DIET HISTORY ON OUR PATIENT PORTAL. This MUST be completed prior to your initial consultation with the doctor. You will receive further instructions on this after you schedule a consultation.
- Psychological Evaluation
As we are a MBSAQIP-accredited Bariatric Surgery Center of Excellence, one of the mandates upon us is that all of our patients must undergo a preoperative psych evaluation. Most of our patients see Dr. Charles Buhrman in our office, but it is not required to use him for this evaluation. (Please note that Dr. Buhrman does not work for our practice, he has his own practice and comes to our office for patient convenience. Separate fees and charges will apply from his clinical evaluation.) We have a number of providers who offer telehealth for psych evaluations as well.
- Referral letter from Primary Care Physician
Ask your Primary Care Physician if he/she would be kind enough to detail your weight-related medical problems and to indicate that he feels the surgery is medically necessary. If your doctor needs more information on the surgical weight loss procedure that you are interested in, let him know that he/she can call us, and we will be happy to send information regarding the surgery. The more detailed this letter is, the better, and it is especially important for them to mention what diets you have done in the past!
Be sure to ask everyone that you speak with to fax us copies of the reports to our office (513-559-1235). You may also want to retain hard copies for your personal records.
SUBMITTING TO INSURANCE
After your first appointment, our insurance coordinator will contact you regarding the specific criteria for your individual plan. When all of the criteria have been satisfied, a Letter of Medical of Necessity will be written. We will then submit your case to your insurance company along with all of your necessary documentation.
The next question patients have is “How long before we get the approval from the insurance company?” This is difficult to predict! Insurance providers are all different with their approval process. It could take anywhere from a couple of days to a couple of months to get the approval. Once you are approved, we will contact you to set up your next appointment!
SELF-PAYING FOR SURGERY
If you do not have surgical weight loss benefits, we can help you with advice for obtaining the necessary financing for self-paying for the operation. In fact, many patients find they spend less money per month after surgery, even including their payment on the operation, due to decreased costs for food, medication, lost wages, etc.
The advantages of self-pay include:
- You can have surgery usually within 4-6 weeks, which is much sooner than if insurance is involved.
- The money you pay out of pocket is potentially tax deductible, which can increase your tax return by as much as $2000-$4000.
- There are multiple ways to finance your procedure (home equity loan, credit cards, etc). You can find more information self-pay pricing and financing here.
Need Help Figuring It All out?
If you have taken the steps above and are still having trouble figuring out if you have coverage, just fill out this form and we can help!