You have finally decided that this the year you are most definitely going to have weight loss surgery…if your insurance company cooperates and approves the request. No matter what month it is when you read this, there are traps for the unwary which you can and should plan for and avoid. You and your surgeon’s office need to think ahead in order to put yourself in the best position to get your insurer’s all-important “YES”!
Let’s look at 3 traps we think you can avoid.
TRAP NUMBER ONE:
“WHAT DO YOU MEAN MY INSURANCE PLAN CHANGED?!?”
Simply put, do you actually have the same insurance coverage you think you have, or that you know you previously had? While many employer-sponsored health insurance plans change with the calendar year (January 1st), there are also a number of plan years beginning July 1st or at other odd times. If your insurance changed from one that excludes weight loss surgery to one that covers it, obviously that is to your benefit. But of far greater frequency and tragedy is the patient who had coverage only to find out he or she lost it when their employer renewed its insurance with a new company. This can happen even when the insurance company itself remains the same because often the scope of coverage changed.
Larger employers with Human Resources personnel or other similar professionals handling the transition from one insurer to another will usually try to make sure that anyone affected will know about changes in advance. But there are those employers who simply don’t know what is (or is not!) covered or they simply don’t care about the impact of the change. So what do you do? The best thing to do is examine for yourself what the coverage is, paying special attention to requirements or limitations for “weight loss surgery,” “obesity treatment” or similar items. Seek out whoever is responsible at the employer to confirm some basic things:
Are they self-insured or fully insured?
Who is the insurer or the claims administrator?
How do I obtain a full copy of the certificate of coverage (maybe called the plan booklet, summary plan description, the policy, etc.)
A word of caution. Remember that the policy is not the book identifying who the providers are (“Provider Directory”) or the 1 or 2 page summary sheet showing deductibles, co-pays, comparisons with your old plan or such similar things that many employers hand out when insurance plans changes. It is a longer booklet that details what is and is not covered and outlines your rights to challenge denials if they occur. Some employers and insurers make it easily available online giving you a user name and password .
You don’t have to tell them why you want this information nor do you have to disclose to them that you’re considering weight loss surgery. But you do have a right to know who your payer is and find out what is (and is not) covered under that plan. Be persistent and you’ll get what you need and what you have a right to have. Once you get it, review the coverage and exclusions carefully to determine whether you have insurance for your weight loss surgery. Call our office at 1-877-99-APPEAL if you need our assistance in learning about your coverage and rights.
TRAP NUMBER TWO:
“WHAT DO YOU MEAN THE 6 MONTH SUPERVISED DIET I WAS FORCED TO DO SINCE LAST YEAR DOES NOT COUNT?!?”
This trap is closely related to the first and causes many patients a great deal of heartache. Let’s say you are committed to having surgery – you have made the decision – but when you went to your surgeon’s office they told you “Well, your insurance requires a 6 month diet plan….come back when you have that documentation.” You’re disappointed but you go away and do as they ask, starting in – say – September of last year. You complete the 6 months and after the surgeon submits the request only to be informed that your insurance changed and does not cover your surgery.
Most people will respond (quite naturally) by saying “That isn’t fair! I was doing what they told me I had to do. Shouldn’t they be forced to cover it since I had coverage when I started this?!?” The answer offered by the insurance company is “No, the coverage in place at the time of your operation is what controls.” Simply starting the diet, even if “they told you to,” does not necessarily create a right for you to get surgery if the coverage changes mid-stream.
How do you deal with that? If you are the victim of that type of denial you can and should contact us immediately to appeal it because those cases can be won. But the real lesson to be learned is to not “Take for Granted” that you have coverage today and assume you will have coverage tomorrow. Once you commit to having surgery, even if you don’t meet every single “criteria,” sometimes you need to work with and convince your surgeon’s office to “submit what you have” rather than wait and risk losing coverage altogether.
TRAP NUMBER THREE:
“I’M NOT SURE I WANT TO HAVE WEIGHT LOSS SURGERY SO I DON’T HAVE TO THINK ABOUT THIS INSURANCE STUFF”
What if you are not yet committed to having surgery? That’s perfectly acceptable. Many reading this are still in the “tire-kicking” phase of your journey. You’re not even sure you want to have surgery and even if you do, which surgery is right for you? An adjustable gastric band? Sleeve? Gastric bypass? Duodenal Switch? “Where should I have this done?” “What program is best for me?” There is much homework to do and doing that homework right is the most important phase of your journey — you want to be sure you are doing the right thing for you! Those who have had surgery (like Walter) will tell you it is not the easy way out so it is best to be sure of your choice and take the time you need in order to be comfortable with your decision. So why do we call this a “trap”? Because from an insurance coverage standpoint many people will waste this precious time when they could be proactive, doing a few things during their research to strengthen any future submission to their insurance company. So if you want to make the insurance process a bit easier in the event you decide to move forward with surgery sometime in the next few years, here’s how to use this time for good.
Payers differ in the details of their so-called “criteria” surgery, but nearly every insurance company wants documentation of a “supervised diet program” as part of their requirements for approval. We can debate another time if they have good reason to require this [they DON'T!] but for now, the questions to consider are “what kind of diet?” and “what kind of documentation?” These tips will help you no matter who your insurance company is or whether your plan is “self-insured” or “fully-insured”. First, know that not every insurance company “accepts” Weight Watchers, Jenny Craig or similar commercial programs. Second, know that not every insurance company “accepts” a diet program supervised by a bariatric surgeon (or a member of that team). To avoid the risk of doing something that you won’t get “credit” for, you want to try to engage in a program that is generally acceptable to most, if not all, insurers. (Remember, whoever insures you today while you “research” may not be your insurer tomorrow when you finally decide to request approval. See Trap #1)
If you have a primary care physician (PCP), and especially one that is encouraging you to investigate bariatric surgery, you are in a good position because almost all insurers will accept a properly documented weight loss program supervised by your PCP. Be aware, however, that some PCP’s may resist or refuse to do it. Some feel they do not have the knowledge or training to get involved with a weight loss program. Some are rightly concerned about reimbursement because often unless there is another reason for your visit to the PCP (for example treatment of your type 2 diabetes, hypertension, GERD, etc.) they risk possibly not being paid for a visit related only to weight loss. However if you communicate with them about what you need and why, you’ll be surprised how they may help.
You see the words “properly documented” earlier in this section? That may be more important to the insurer than whatever type of diet program the doctor places you on. For starters, “properly documented” does NOT mean a summary letter from your doctor of 15 years telling “To Whom It May Concern” that he/she has supervised you through many weight loss attempts without success. While everything in that letter may be true, most insurance companies do not accept it as “documentation” so don’t put all your eggs in that basket. You need more than that.
So what are they looking for? They are looking for chart notes showing your visits with the doctor – generally on a monthly basis and you must weigh in. Payers are looking to see that you and your doctor discussed your eating plan, that you are trying to follow a reduced calorie diet of some sort, that you are (to the best of your physical ability) trying to incorporate exercise, and that you are working to modify your behaviors about food. A food diary will never hurt. However your PCP charting these visits on a consistent monthly basis while you do your research and make this important decision will serve you well if you decide to have surgery in the future!
When it comes to bariatric surgery, insurance companies continue to present challenges and obstacles for us patients, even in the face of overwhelming medical evidence about its benefits. However knowledge is power and if you know about and avoid these traps, you can put yourself in the position to get them to say “YES” or be able to successfully fight them if they dare tell you “No”! It is a fight worth fighting and a fight worth winning!