Most states have passed legislation that requires health insurance companies to provide weight loss surgery benefits for obese people who meet the National Institutes of Health criteria for this procedure. However, the amount of reimbursement people receive varies widely, and the approval process tends to be detailed and lengthy. Furthermore, despite legislation, some insurance policies specifically exclude obesity treatment or have such strict criteria for bariatric surgery that many people fail to qualify.
The following tips can improve your chances of getting your insurance company to approve your request for weight loss surgery benefits:
Read and understand your insurance company’s certificate of coverage.
Take the time to read and understand your insurance company’s “certificate of coverage.” You can get a copy of this document from your employer’s human resource department, or you can request a copy directly from your insurance company.
Get a referral or prior authorization for your visit with Hollywood Bariatrics.
Depending on your insurance carrier and coverage, you may require a prior authorization from your primary care provider before your initial consultation with Hollywood Bariatrics.
Keep detailed records of conversations with your insurance company.
Document every conversation you have with your insurance company’s representatives regarding weight loss therapies. Ask for the employee’s name or employee ID and jot down this information along with the date and time of the call and a brief synopsis of the information the insurance company employee gave you. This will help you remember exactly what they require from you to meet eligibility and this information may come in handy if they later try to reverse their claim.
Document all weight-related expenses.
Provide details and receipts for every visit you made to healthcare professionals for treatment of obesity or obesity-related health issues within the past few years. Also provide receipts for any commercial weight loss programs, diet centers, and/or fitness clubs you have joined.
Work with your primary care physician and bariatric surgeon on the insurance authorization process.
If you are a suitable candidate for bariatric surgery, we will assist you with the insurance authorization process. Usually we will need your primary care physician to provide written documentation that weight loss surgery is medically necessary for your health.
Your primary care physician must provide documentation verifying that you:
- Are morbidly obese with a BMI of 40 or greater, or that you have a BMI of between 35-39.9 and potentially life-threatening, weight-related health problems like diabetes, sleep apnea, high blood pressure or heart disease.
- Have been seriously overweight for at least 5 years.
- Have attempted medically supervised weight loss therapies such as weight loss medications, behavioral support groups like Overeaters Anonymous, or medically monitored weight loss programs like OPTIFAST® or Medifast® for at least 2 years without success.
- Have no history of substance abuse, including alcoholism.
- Have had a thyroid test, and that the results will be supplied to the surgeon.
The letter should also indicate if you have serious kidney, liver, or gastrointestinal disease.
What if your request for coverage is denied?
Insurance companies are required to allow people to appeal the company’s coverage rulings. The trick is to understand the reasons you were turned down then appeal the decision quickly by providing documentation that address the insurance company’s specific concerns.