Insurance and Financing

Weight loss can change your life and significantly improve your health. You may also find that dramatic weight loss can greatly reduce weight-related costs, which on average can be more than $14,000 a year! What better investment could you make in yourself and your future?

In an effort to provide a simple understanding about insurance and financing we will separate the two.

Insurance

Most insurance companies offer the benefit for bariatric surgery. It is up to the employer to choose to include the benefit in their employee policy. When you call to check with your insurance company, ask them if your policy includes “medically necessary weight loss surgery”.  Many insurance policies now require 3 to 12 continuous months of “medically supervised weight management”. Every policy is different. Your members benefits booklet or insurance company website should list the exact requirements that apply to you.

The following are some of the key steps you should take to obtain insurance coverage for your weight loss surgery:

• Read and understand the “certificate of coverage” that your insurance company is required by law to give you. If you do not have one, consult your company’s benefits administrator or ask your insurance company directly.
• You may be required to start with your primary care physician. In some cases, they are the only ones you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is still a good idea to have the support of your primary care physician during this process. Our program actually requires that we have a referral from your primary care physician even if your insurance policy does not. We want to know that your physician completely supports you in the decision to have weight loss surgery as we will work together with him/her to assist with your long term success.
• Before visiting Southern Oregon Bariatric Center, organize your medical records, including your history of dieting efforts. They will be valuable documents to have at every stage of the approval process.
• Document every visit you make to a health care professional for obesity-related issues or visits to supervised weight loss programs. Document other weight loss attempts made through diet centers and fitness club memberships. Keep good records, including your receipts.

If your surgeon recommends weight loss surgery, they will prepare a letter to obtain pre-authorization from your insurance company. The goal of this letter is to establish the medical necessity of the weight loss surgery and gain approval for the procedure. The following information is generally included in the pre-authorization letter:

• Your height, weight, and Body Mass Index, and any documentation you might have as to how long you have been overweight.
• Simply describing your condition as morbid obesity is not enough. You will also need to include a full description of all of your obesity-related health conditions including records of treatment, a history of medication taken and documentation of the effects these conditions have had on your everyday life.
• A detailed description of the limitations your excess weight places on your daily activities such as walking, tying shoes, or maintaining personal hygiene.
• A detailed history of the results of your dieting efforts, including both medically and non-medically supervised programs. You will need to include medical records, records kept of payments, and meetings attended with commercial weight loss programs.
• A history of exercise programs, including receipts for memberships in health clubs if available.
• Ask your doctor to include information from medical journals regarding the effectiveness of weight loss surgery, particularly information showing the control or elimination of obesity-related health conditions.

Thirty days is the standard time for an insurance provider to respond to your request. You should initiate a follow-up if you have not heard from your insurance company in that time. For SOBC, we know you are eager to learn of the insurance approval; therefore, we generally follow-up with the insurance company 2 weeks after submitting the request and keep you posted with any information we learn as we go.

The Appeal Process

Even if your initial request for pre-authorization is not approved, you still have options available. Insurers provide an appeal process that allows you to address each specific reason they have given for denying your request. It is important you reply quickly. We recommend you enlist the help of an experienced insurance attorney or insurance advocate to properly navigate the complexities of the appeal process. Some insurers place limits on the number of appeals you can make, so it is important to be well prepared and that you clearly understand the appeals rules of your specific plan.

If you and your surgeon have selected the LAP-BAND® System as your procedure of choice and have encountered resistance from your insurance company, you are in luck. Allergan, the manufacturer of the LAP-BAND® System will pay for the insurance attorney to appeal the case. We will walk you through initiating the appeal and standby to support as best we can.

If you still have questions, once you have attended our Bariatric Symposium, our office will be happy to help you sort this out.

Financing

If you do not have insurance benefits for surgery, you may be eligible for financing. Check out the Affordability Calculator on our home page to give you an idea of the costs involved then contact our office for details. We will be happy to be of assistance!

Whether you are financing surgery or have insurance benefits available, congratulations! You are on your way to a healthier body and life! Be proud of yourself for taking these steps. If you are still wondering how you are going to pay for surgery, you can also be proud of yourself for making the decision to figure this out. Persistence pays. Stay positive and don’t give up! Contact our office today for more information.

Mymedicalloan.com and surgeryloans.com are two lenders that our patients have had success with. We have no affiliation with these organizations and offer these merely as suggestions. Click on the image above for more information!