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August 08, 2006

Gastric Bypass Insurance and Financial Information

Insurance_claim_1 I have been asked too many times about insurance companies and their WLS policies… So my advice is, get a copy of "Insurance Secrets" here, and continue to read ahead:

An operation such as the Gastric Bypass requires an average of 3 - 4 days in the hospital, and from one to six weeks of recovery afterwards, depending on the method of operation, your condition, and the type of work you do, before you can return to full activities.

The cost of the operation usually includes: Hospital charges, Surgeon's fee, Surgical Assistant's fee, Anesthesiologist's fee, Laboratory charges, X-Ray charges and Consultant fees - as necessary

Bariatric surgery is covered by many insurance policies, and the amount which it costs depends upon the type of policy and its terms, as well as any contractual arrangement with the hospital. Insurance coverage come in many types, and coverage really cannot be predicted, since they vary from policy to policy, even when issued by the same insurance company. If you wish to come to us for evaluation and surgery, we perform the insurance authorization and approval process without charge. With specific policy information and approval, we can obtain your out-of-pocket expected costs before you schedule surgery.

Many patients choose to pay for the operation themselves. Many surgical centers offer special packages for cash patients, which include all usual services, at a substantial discount. The actual rate varies, depending on the type of surgery chosen, and initial weight and health status.

It is best to remember that insurance companies make money, and profits, by collecting premiums - that's their business. Every bit of care you receive, and which they have to pay for, decreases their profit. In general, we've observed the following:

Indemnity Insurance policies (the type where they pay 80% and you pay 20%) will often cover surgery for medically necessary treatment of clinically severe obesity. Preferred Provider Organizations (PPO) often will cover surgery, when medically necessary. They want you to remain in their network, because it costs them less. This also means they may contract with a surgeon who has little or no experience in bariatric surgery, because it costs them less.

Managed Care Organizations of various forms, such as HMOs, will usually try to avoid coverage of bariatric surgery. They usually have a "primary care" doctor, also known as a "gatekeeper", who is supposed to evaluate your need for expensive surgeries -- and he often suffers a financial loss if he recommends it. The key to dealing with these organizations is that they usually do not specifically exclude coverage in their contract, and if it can be shown that treatment is medically necessary to preserve life or health, they will have to provide it. Once again, they will try to contract with the lowest bidder, regardless of experience or skill.

Medicare covers weight reduction surgery under certain specific criteria, which they use to determine if it is medically necessary. The most important criterion, which must be met, is that one must be completely disabled for work, or from ordinary activities of daily living.

MedicAid (MedicAid) will generally deny an application for surgery. However, a determined person who can clearly show medical necessity can obtain coverage for treatment.

Medical Necessity

As you may have noticed above, the need for surgery, and the coverage by insurance, usually depends upon the determination that surgery is medically necessary to improve health, to reduce risks to life, and to permit a normal lifestyle. It also depends upon the determination of the person seeking care, in developing the arguments for surgical treatment, and in accumulating corroborating information, and physician opinions, to substantiate the medical necessity.

The process of getting coverage involves several steps, and various strategies, depending upon the type of insurance, and the specific practices of the insurance company.

The Medical History

A thorough Medical History must be obtained, in which the specific the course of development of serious obesity is made clear, current weight and height are measured, and Body Mass Index is calculated. The efforts to achieve weight control by non-surgical methods are described in detail, and each of the specific co-morbidities with which you are afflicted are identified and characterized. From this history, a detailed picture of current health status, and the adverse effects of obesity can be demonstrated.

Supporting Documentation

A brief letter from physicians who have treated you, especially specialists who have cared for a weight-related health problem, can be very valuable. Ask your doctor to state that your health problem is related to your excess weight, and that weight loss is indicated, or medically necessary, to relieve it.

Insurance carriers often want proof that you have dieted, under supervision of a physician - even though no one has ever shown scientifically that diets have any therapeutic benefit in the seriously obese. If you have been through a diet program, such as those with medications, HCG shots, hypnotism, acupuncture, psychotherapy, behavior modification, even powdered eye-of-newt, try to get records, receipts, or a statement from the doctor that you tried it.

Medical Testing

In some cases, the history may show the need for medical testing, to measure and clarify the degree of health risk of a given co-morbidity. For example, a diagnosis of Sleep Apnea syndrome may need to be confirmed by sleep study, when symptoms suggest that it is present. In most cases, diagnostic tests support and corroborate the indications for surgery, and can be quite helpful in obtaining needed treatment. Sometimes, insurance carriers demand tests, such as psychological or psychiatric evaluation - this is not really a problem, since few overweight persons are so seriously affected emotionally as to be unsuitable for surgery.

Insurance Request

Once the indications for surgery have been evaluated, and needed testing is accomplished, a request can be made for the health care benefits. The method of this request varies with the type of coverage:

Indemnity Insurance & PPO Insurance Plans

Your surgeon's office will prepare and submit a letter to your insurance carrier, requesting certification of your insurance coverage, and authorization for you to proceed with surgery, with their surgery center. This letter will be detailed and specific, stating each of your indications, and the corroborating information. If they issue an initial denial, your surgeon's office should try to pursue an appeal, with further arguments.

Health Maintenance and Managed Care Organizations

HMO's and the like might not accept a letter or request from you or your directly. However, your doctor can prepare a version of his/her request letter, addressed to you, which details the severity of your weight-related health problems, and the desirable further testing to be done. Armed with this information and knowledge, you can approach your "gatekeeper" doctor and request consideration for surgery. Ultimately, you may need to pursue a grievance process, or request an arbitration hearing, to obtain the care you need. Most persons who have valid indications, and who persevere through the whole process, will prevail in the end. Your HMO will want to refer you to a contracted surgeon - be sure that this is a surgeon with current experience and competence in bariatric surgery, operating in a comprehensive surgical weight control program, as recommended by the NIH Consensus Panel.

Medicare

Under Medicare, the Gastric Bypass is available only as an open operation, not laparoscopically. The Laparoscopic Adjustable Silicone Gastric Band procedure, an investigational device and operation, has been granted an exemption by MediCare and is an available procedure at this time. Medicare specifies criteria for bariatric surgery. Your doctor's office will determine if you meet these criteria, based upon your medical information and measurements. If you do not meet criteria, there is essentially no appeal - but you can always write to your legislators, and try to leverage the system.

MedicAid

Regulations in this program vary from state to state, and most states will require that surgery be done in your home state, if it is available there at all. Some patients will find the initial response discouraging, but where clear medical necessity exists, they can obtain coverage through perseverance, and possibly some legal aid.

If You Get a Denial

Many insurance companies will deny an initial request, even when well-substantiated, and well within the consensus criteria recommended in the NIH report. When faced with a determined appeal, from a determined person, they will often relent, and provide coverage, to avoid a confrontation.

If your insurance carrier remains unreasonable, you may wish to seek legal assistance in obtaining good faith coverage of your medical needs.

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Comments

Maria Charron

My name is Maria and I am a teache in West Palm Beach County. I'm 31 years old and 380lbs. I have been trying for over a year to get approved for gastric by pass and all my insurance (United Health)says is that it is not covered under my policy. I am desperate. I have many health conditions related to being morbidly obese and I have a severe family history of heart atacks, diabetes and higj blood preasure. I want to be able to enjoy my life again. Can somebody help me??

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