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Deciding to have weight loss surgery is a very big decision. The process generally begins by checking with your insurance carrier about coverage of benefits. Our office will do this for you when you call to make an initial consulation.
Medicare, Medicaid,and most major plans cover weight loss surgery.
We check all benefits before scheduling your initial appointment. Unfortunately, some insurance plans do not have benefits for weight loss surgery. We have found it helpful to call the insurance company’s customer service number and ask if:
is a covered procedure for the diagnosis of morbid obesity.
Be sure to ask your insurance carrier specifically if surgical treatment for morbid obesity is an excluded benefit. Sometimes repeated calls to different customer service agents yields different answers. Our office staff is happy to assist you in understanding your insurance benefits and will call on your behalf to make sure you get accurate information. You will either be told that it is covered if “medically necessary,” or that it is not a covered procedure.
If it is covered when “medically necessary” we will assist you in obtaining prior authorization. If it is not a covered procedure, then choices are often limited except for a cash pay option (see below). Some insurance companies have additional requirements that vary from one policy to the next. This may include attending preoperative support group meetings or undergoing 3- or 6- month medically supervised diets which can be performed by our staff or your personal doctor. Proper documentation will be necessary. Please call us so we can ensure that your attendance is properly docmented to meet the insurance requirements. This is very important and patients are often denied coverage due to poor or incomplete documentation. Obtaining authorization from your insurance company for obesity weight loss surgery can be a challenging and frustrating process. Our staff are experts in navigating these hurdles, but your cooperation and compliance is paramount. We can not do this without your help in obtaining the necessary information.
We need as much documentation as you can provide regarding your attempts at dieting and, in particular, any medically supervised diet plans.
Documentation of any associated medical problems such as:
Obtaining approval can take several weeks to complete. Many companies deny an initial request for no apparent reason, despite their policy of utilizing national criteria in patient selection. In the event you receive a denial, you need to go through the proper channels and appeal. We will assist in this matter, but the appeal must come from the policyholder. Our experience shows that many companies will back down and approve coverage when faced with a determined patient.
More and more policies are now requiring 3- or 6- month “Medically Supervised Diets,” documenting failure to loose weight prior to authorizing weight loss surgery. Diet programs such as Weight Watchers™, etc. do not count. This diet can be done by your primary doctor or through our medically supervised diet program with Dr. Boland. You can contact our office for the information and forms to provide your primary care doctor to start this process.
The documentation must include:
Vital Signs, including weight Current dietary program and progress with the program Physical activity (i.e.: exercise program) Behavioral interventions to reinforce healthy eating & exercise habits Consideration of pharmacotherapy with U.S. Food & Drug Administration (FDA) approved weight-loss drugs, if appropriate.
In conjunction with Trinity Hospital of Augusta and Doctor’s Hospital, our practice offers a cash-pay option for those patients that do not have insurance coverage. This option is one comprehensive fee that includes:
All hospital fees to include preoperative labs, x-rays and hospital stay surgeons fees anesthesia fees BLIS Care Insurance (post-op warranty against certain complications). www.bliscompany.com/ First year post operative care/band fills.
Not all self-pay plans by other programs are the same. Make sure that you understand what is covered. Although we don’t expect to have complications, when it does happen the expense can be costly. This is why all of our patients are covered by BLIS Insurance, which can be a financial lifesaver.
For further questions about self pay options please contact at 706-922-0440 or by email.
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