- Will my health insurance pay for the procedure?
- Although most insurance companies in Iowa pay for bariatric surgery if the surgery is medically necessary, many of them also require specific criteria be met before giving approval. Please check with your health care plan to determine whether you meet their criteria. If you do not have insurance and are interested in participating in our self-pay program, please call 319-356-1887 for information.
- A growing number of states have passed legislation requiring insurance companies to provide benefits for weight-loss surgery for patients that meet the National Institutes of Health (NIH) surgical criteria. While insurance coverage for weight-loss surgery is widespread, it often requires a lengthy and complicated approval process. The best chance for obtaining approval for insurance coverage comes from working together with your surgeon and other experts.
- Here are some of the key steps you should take to obtain insurance coverage for 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, he or she is the only one you can ask for a referral to a qualified bariatric surgeon. Even if you are not required to get a referral, it is a good idea to have the support of your primary care physician.
- Before visiting the bariatric surgeon, 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 healthcare 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 receipts.
- If your surgeon recommends weight-loss surgery, he or she will prepare a letter to obtain pre-authorization from your insurance company. The goal of this letter is to establish the medical necessity of 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 (BMI) and any documentation you might have as to how long you have been overweight.
- Simply describing your condition as morbid obesity is not enough. A full description of all your obesity-related health conditions, including records of treatment, a history of medications taken, and documentation of the effects these conditions have had on your everyday life is necessary.
- 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 medically and non-medically supervised programs, medical records, and records kept of payments to and meetings attended with commercial weight-loss programs.
- A history of exercise programs, including receipts for memberships in health clubs.
- 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.
- Most insurance companies recognize the health consequences of obesity and cover the costs of the surgical management of weight-loss in qualifying patients. However, every insurance plan is different.
- Because of this, we coordinate patients' insurance applications. Once the physician has recommended surgery, we start the process to obtain insurance authorization. We begin by sending a letter to your insurance company requesting coverage for the surgery. It usually takes about four to six weeks for the insurance company to approve the application.
- We will call you once we receive word from the insurance company of approval or denial. If the coverage is approved, a surgery date and pre-op appointment are scheduled for the patient. If coverage is denied, we resubmit the application and go through the appeal process with the insurance company.
- How does the appeal process work?
- 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 that you reply quickly. It is also recommended that, at this point, 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 may make, so it is important to be well prepared and that you clearly understand the appeal rules of your specific plan.
- Why does it take so long to get insurance approval?
- After your initial consultation is completed, it usually takes your doctor one to two days to send a letter to your insurance carrier to start the approval process. The time it takes to get an answer can vary from three to four weeks or longer. UI Hospitals and Clinics insurance analysts will follow up regularly on approval requests; we’ve found that patients who also follow-up help speed this process. It may also be helpful to call your insurance company’s claims service seven days after your letter is submitted to inquire about your request status too.
- How can a life-threatening disease be denied for insurance coverage?
- Payment may be denied because there may be a specific exclusion in a patient’s policy for obesity surgery or "treatment of obesity." Such exclusions can often be appealed when surgical treatment is recommended by a surgeon or referring physician as the best therapy to relieve any existing life-threatening obesity-related health conditions, which usually are covered. You will need to contact the benefits manager within the insured’s place of employment and ask for an exception to policy.
- Insurance payment could also be denied for “lack of medical necessity." A therapy is deemed to be medically necessary when it’s needed to treat a serious or life-threatening condition. In the case of morbid obesity, alternative treatments such as dieting, exercise, behavior modification and some medications are considered viable and available. Medical necessity denials usually hinge on the insurance company's request for some form of documentation, such as one-to-five years of physician-supervised dieting or a psychiatric evaluation proving that you’ve tried unsuccessfully to lose weight by other methods.
- What can I do to help the process?
- Gather any documentation (diet records, medical records, medical tests) your insurance company may require. This reduces the likelihood of a denial for failure to provide necessary information. Letters from your personal physician and consultants attesting to medical necessity of treatment are particularly valuable. Several physicians reporting the same findings may help confirm medical necessity for surgery.
- Once the letter is submitted, call your carrier regularly to ask about the status of your request. Your employer or human relations/personnel office may also be able to help you work through unreasonable delays.
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University of Iowa Hospitals and Clinics
200 Hawkins Drive, 4604 JCP
Iowa City, IA 52242