Bariatric Surgery Payment Options & Insurance
Although weight loss surgery is endorsed by the National Institutes of Health as the only safe and effective treatment for morbid obesity, not all insurance policies cover the full costs of weight loss surgery. Many insurance carriers offer a benefit for weight loss surgery procedures, but each company writes a wide variety of plans with different requirements. For instance, some plans will cover only certain types of weight loss surgery, while other plans specifically exclude coverage of any weight loss surgery. As the patient and policyholder, you are responsible for determining what your particular policy will or will not cover. Our experienced staff will work with you and your insurance provider to achieve pre-authorization for your surgical procedure. The first step in determining your coverage is to contact your insurance carriers' member services by calling the number listed on your insurance card. If the member services number is not listed, contact the person at work who manages your insurance policy to obtain that information.
The following are questions to ask your insurance carrier before you submit your new patient packet if you plan to use insurance as your form of payment:
1. Do I have a benefit for weight loss surgery?
- If "Yes"...Your Insurance Carrier Provides Coverage If your insurance carrier covers weight loss surgery, ask them what procedures they will cover and what the criteria is for using your benefit. Use this information to determine whether you qualify for coverage. Some carriers will tell you this information can only be given to the medical provider, your doctor. This is incorrect. As a premium-paying policyholder, you have a legal right to know what is required to utilize your benefits. Made sure to document the name and extension of the person you discussed the coverage limits with.
- If "No"...Your Insurance Carrier Does Not Provide Coverage In this case, you do not have a benefit and your insurance company will not pay for any procedure. This means that when your employer selected an insurance company and a specific plan with specific benefits to provide health insurance to the employees, they did not choose to pay for, and include, weight loss surgery as a benefit in the overall plan. If you want the procedure, you will need to consider patient financing or paying cash as other options.
2. What Type of Plan Do I Have: PPO or HMO?
Whether or not you have a PPO or HMO plan is important because it determines the surgeon and hospital your insurance plan authorizes. In general, PPO plans allow you much more flexibility in choosing your physician and program.
- PPO Plans - Ask If Your Policy Provides Out-of-Network Benefits PPO plans generally have out-of-network benefits that allow patients to select their physician of choice. Benefits are slightly reduced when choosing an out-of-network doctor, which will result in some out-of-pocket expenses for the patient. Your specific plan will determine what out-of-pocket expenses you will be responsible for.
- HMO Plans HMO plans generally do not allow members to obtain surgery outside of the network. They may generate a referral for a consultation but will not provide a referral for surgery.
3. What happens if my insurance company denies the procedure?
The most proactive decision would be to meet the requirements implicated in the denial. Over 90% of denials are due to not meeting one or more requirements of the health plan. The most common prerequisites include documentation of:
- Six month medically supervised weight loss program.
- Morbid obesity for 3-5 years
- Letter of referral from a physician who supports the surgery
- Medical problems related to obesity
Get started today!
The first step is to complete a new patient information packet and attend a new patient seminar (either online or in-person). Our verification specialists will then conduct a thorough insurance review to determine your unique health plan requirements and coverage limits. Call 480-882-7460 with any questions.