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Is Bariatric Surgery Covered by Insurance

November 4, 2019 | Bariatric Surgery

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Weight loss is challenging, especially if you have a lot of weight to lose. If you’ve been unsuccessful in trying diet and exercise alone, bariatric surgery may be the solution. There are different types of weight loss surgeries, and sometimes these procedures are medically necessary when an overweight person’s health is in danger. It can be expensive, though, so you may be wondering: is bariatric surgery covered by insurance?

It’s a valid question because bariatric surgery is expensive. The cost of bariatric surgery varies based on the type of surgery you’re having, the surgeon’s fee, and the hospital you choose, but it will typically run between $20,000 and $25,000. There will be additional fees as well, for the anesthesiologist, the surgical assistant, any devices or consultants, and follow-up procedures.

If you have health insurance, it very well might cover the procedure. In some states, coverage for bariatric surgery is mandatory under the Affordable Care Act. What’s more, insurance companies understand that people who are overweight or obese are at a higher risk for some serious health conditions, including type 2 diabetes, high blood pressure, cardiovascular disease, high cholesterol, and sleep apnea. Read your policy carefully, and work closely with your doctor and insurance company, so that you’ll know exactly what’s covered.

Even if you’re covered, the process of getting your insurance company to pay for your weight loss surgery may be complicated. Most insurance companies will require extensive documentation, including the proof from your surgeon that medical intervention is medically necessary, participation in a physician-supervised diet program, a psychological evaluation, and nutritional evaluation. Before they pay for such an expensive procedure, they want to make sure that you’re going to commit to the necessary lifestyle changes that go along with bariatric surgery.

Once you’ve completed all the required steps, your surgeon will send a preauthorization request letter to the insurance company, outlining your medical history and health problems, and confirming that you’ve done everything required of you. The insurance company will review your case, request specific diagnostic tests if necessary, and decide whether or not to cover you. It’s very important that you keep accurate notes and save all communications with the company and your surgeon, as well as copies of completed insurance forms. If the request is denied, or the insurance company declines to pay for the entire procedure, write a letter of appeal must be written to the person at the insurance company who denied the claim.

Before sending a letter of appeal, it’s important to really understand the insurance policy. This means determining whether or not the desired procedure is excluded from coverage, and if any restrictions were in place when the contract began. Included with the appeal letter, there needs to be an explanation of why it’s important for the surgery to be covered, a request for full explanation of why coverage has been denied, a request for a copy of the specific statement that explains why the coverage was denied or limited, a copy of the denial notification, and a copy of the doctor’s preauthorization request letter. A copy of the appeal letter should be sent to the state insurance commissioner or, if the patient is covered by an HMO plan, the department of corporations. The surgeon can help prepare a statement, explaining the problem being faced and asking for assistance. It’s a lot for a patient to tackle, and can often be confusing and overwhelming for patients who have to go through this whole process on their own. That’s it’s helpful to choose a surgical center that includes not only a top-notch medical team but also a billing department that serves as an ally and advocate for patients.

One thing that sets Garden State Bariatric and Wellness Center apart from other providers is that we manage the insurance process for our patients. We want to take away the stress, mystery, and work, so we complete the benefits verification process for you, speaking directly with your insurance company about your specific plan. We’re able to accept most insurance with out-of-network bariatric benefits, and we promote a no-surprise billing philosophy. This means that all of our patients know their out of pocket costs for surgery ahead of time, and it’s all in writing. Our billing department advocates for our patients, and if insurance fails to cover something or pays incorrectly, we do the legwork to get those issues resolved, so you don’t have to manage it.

If you’d like to learn more about weight loss surgery, Garden State Bariatrics can help. An MBSAQIP accredited bariatric practice, we provide surgical and ongoing medical care to help patients reach their surgical, nutritional and lifelong goals. Passionate about our work and committed to our patients’ success, we will do everything possible to assist you in living your best life.

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